Conference news
Michel Kazatchkine presenting at the European AIDS Conference. Image credit: mtvisuals.com
The European region needs to step up prevention and treatment activities if it is to reach the UNAIDS target of 90% diagnosed, 90% of those diagnosed on treatment and 90% of those on treatment with fully suppressed viral load by 2020, the United Nations Secretary-General's Special Envoy on HIV and AIDS in Eastern Europe and Central Asia told the opening session of the 15th European AIDS Conference in Barcelona last month.
“Europe is not done with AIDS and there is no room for complacency,” Professor Michel Kazatchkine told delegates. “If we do not intensify our efforts in the next five years we will not be on the path to ending AIDS.” He singled out low levels of testing in men who have sex with men and alarmingly low rates of treatment and retention in care in HIV-positive people in eastern Europe as two of the biggest problems that need to be solved.
Kazatchkine was speaking at one of three international meetings the aidsmap.com team attended recently.
The 15th European AIDS Conference and the 24th International Harm Reduction Conference both have dedicated conference pages on our website, where you can also view our conference summary bulletins.
We also attended the fourth IAPAC Controlling the HIV Epidemic with Antiretrovirals summit. You can read a news feature on the presentations detailing progress towards better treatment access on our website.
At least 25,000 people in the US may now be using PrEP
Up to 30,000 people in the US may now be taking pre-exposure prophylaxis (PrEP) to prevent HIV, the fourth IAPAC Controlling the HIV Epidemic with Antiretrovirals summit in Paris heard last month. A survey of US pharmacies that dispense PrEP found 8512 individuals who had had Truvada (tenofovir/emtricitabine) prescribed to them as PrEP from the beginning of 2012, more than double the prescriptions in the previous year. The true number of people on PrEP, however, is considerably higher. Only 39% of US pharmacies are participating in the PrEP survey so there could have been nearly 22,000 PrEP prescriptions since 2012, if non-reporting pharmacies prescribed PrEP at the same rate as reporting ones. In addition to pharmacy-prescribed PrEP, an estimated 8000 people are receiving PrEP in demonstration studies, through the US Medicaid system, or via the patient assistance programme operated by Truvada manufacturers Gilead. This adds up to nearly 30,000 people, though the true figure is likely to be somewhat lower, as non-reporting pharmacies may be prescribing less PrEP and also because some people may have already stopped PrEP.
In contrast, Europe-based speakers at the IAPAC summit expressed frustration with the rate of progress towards achieving access to PrEP here. Jean-Michel Molina, principal investigator of the Ipergay study, said that the French Ministry of Health had now asked an expert panel and the French National AIDS Council to give recommendations for PrEP provision “…but not too soon.” He said this posed a possibly dangerous situation, with more and more people asking for PrEP and, as a survey by AIDES recently documented (link in French), rising rates of informal usage of PrEP and requests for post-exposure prophylaxis (PEP) as a way of getting PrEP. Sheena McCormack of the PROUD study said that she thought that the fears of European PrEP providers of an unaffordably high demand for PrEP were misplaced: “I think that we will struggle to get all those who need PrEP to recognise or accept they are at sufficient risk to need it,” she commented.
Dominique Costagliola of ANRS, the French HIV research agency, said that despite the fact that 94% of people diagnosed with HIV in France are receiving antiretroviral therapy (ART), HIV prevalence in men who have sex with men (MSM) was now 17% and annual incidence was 1.04% – six times the rate in people who inject drugs and 13 times the rate in women who were not French nationals, the next two highest-risk groups. “There is a critical situation of MSM in Europe,” she said, “which is unlikely to be controlled by more HIV testing and the offer of ART at diagnosis.”
Comment: PrEP may not be the ‘magic bullet’ that reduces the HIV infection rate in gay men – it’s too early to say, though Bob Grant of iPrEx showed data from San Francisco at the same meeting suggesting it might be starting to have an impact on new diagnoses in gay men. Whatever PrEP’s public health impact, its continued unavailability in Europe is starting to become a scandal – and a danger, if gay men turn to acquiring PrEP online or via friends and start taking it without proper monitoring. The Dean St Clinic in London is now offering a private PrEP clinic and tests for those buying PrEP online, and Jean-Michel Molina announced at the European AIDS Conference that a clinic in Paris will follow suit soon.
Most migrants living with HIV in Europe acquired HIV in their new country
A study presented at the 15th European AIDS Conference last month found evidence that the majority of migrants living with HIV in Europe diagnosed in the last five years probably acquired it in their host country rather than the country in which they were born. The aMASE study found that the proportion of people with a documented or probable date of HIV infection later than their move to, or within, Europe was higher than those with a documented or probable pre-migration infection date, and that this applied to all risk groups, all areas of origin, and both sexes. In many cases, the date of infection could not be narrowed down. But even in sub-Saharan Africans, while 22% of those living with HIV in Europe had probably acquired HIV in their country of origin, 31% had acquired it in their host country. The predominance of infections acquired in Europe was much higher in people from other parts of the world, who were predominantly gay men. Sixty-eight per cent of people from Latin America and the Caribbean had probably acquired HIV after migrating and 8% before; 57% of Asians after and 18% before; 58% of eastern Europeans after and 12% before; 60% of central Europeans after and 8% before; and 69% of western Europeans after and 12% before.
So acquiring HIV was anything between three and eight times more likely in the country people moved to rather than the one they came from. However, this was not just a gay male phenomenon: 36% of heterosexuals, both men and women, had acquired HIV in their host country and only 18% of women and 13% of men had definitely acquired HIV in their home country. Débora Álvarez del Arco of aMASE called for more research into migrant vulnerability to HIV in the countries to which they migrate.
Comment: This study’s methods mean that date of infection is only an estimate in most cases, but nonetheless the results are genuinely surprising: even for African heterosexuals and very strongly for gay men, Europe is now a higher-risk HIV environment for migrants than their home countries (and western European countries for migrants from eastern Europe). This may be for several reasons: migrants embracing the new freedom their move enables may be one, relatively greater prosperity another. Equally, however, racism and exploitation, including within the gay scene, loneliness and lack of peer support may also play a role. One thing that is notable is that very few of the big cities that are Europe’s magnets for people at risk of HIV provide anything like enough HIV information and support directed to migrants, particularly information in native languages.
Peer workers improve drug users’ engagement with HIV care in Ukraine
An innovative programme in which peer outreach workers use a case management approach to help HIV-positive people who inject drugs to engage with medical services and to begin antiretroviral therapy appears to be paying off, according to early results presented to the 24th International Harm Reduction Conference in Kuala Lumpur last month. The International HIV/AIDS Alliance in Ukraine was concerned that despite referral to government-run HIV treatment services, few people who inject drugs were effectively linked to and retained in care. The new approach involved harm reduction peer outreach workers shifting their focus purely from needle exchange to, in addition, helping HIV-positive clients engage with HIV treatment services. The aim is to improve the HIV treatment cascade for this key group in Ukraine’s HIV epidemic. The outreach workers take on a mediating role between the patient and the doctor, advocating to ensure that patients receive the services they are entitled to.
Three-quarters of project users were actively engaged in medical care, compared with 35% of HIV-positive Ukrainians who inject drugs in general and 26% were on antiretroviral therapy (ART) compared with 9%. This is still too low, partly because people with a CD4 cell count above 350 cells/mm3 (41% of project clients) are not eligible under the country’s treatment guidelines. Further, significant barriers remain in the health system – an unwillingness to treat people who continue to use drugs and interruptions in the provision of antiretroviral drugs.
“Some people do not like doctors and hospitals, especially stigmatised people such as our clients,” commented Pavlo Smyrnov of the International HIV/AIDS Alliance in Ukraine. “But we were also hearing of doctors telling users they must come off drugs first before they can think about receiving ART. In more extreme cases, we have even heard of doctors asking drug users to give a written statement saying they don’t want to begin ART until they have stopped using drugs.”
Comment: It is too early yet to get excited about projects to engage more people in care in eastern Europe and to try to improve the dismal rates of ART coverage and viral suppression there. Projects like this, however, will be a sign of change if national health services as well as NGOs start to endorse them.
London clinic survey shows impact of chemsex
A survey of gay men in London using drugs during sex – chemsex – has shown high levels of unprotected sex and hepatitis C among both HIV-positive and HIV-negative men, high levels of post-exposure prophylaxis (PEP) use and a high frequency of injecting drug use. The study included 874 men who attended a chemsex support service over one year at the 56 Dean Street clinic, London’s busiest sexual health clinic. 56 Dean Street serves over 11,000 clients a month, 7000 of them men who have sex with men and approximately 3000 of them using drugs. The chemsex support service sees around 100 gay men each month. Men who attended the clinic were a self-selecting group who had concerns about drug use during sex, but previous surveys in London have reported that at least 19 to 25% of men attending sexual health services reported using party drugs during sex.
Thirty-two per cent of men were living with HIV (280 men). This includes 42 men who were not taking antiretroviral treatment and the majority of these men reported no condom use (64%). Attendees with HIV tended to report accelerating use of drugs for sex after their HIV diagnosis. Among men on treatment, condom use was somewhat higher, but 25% reported no condom use at all, and 10% of the HIV-negative men reported no condom use. Thirty per cent of HIV-negative men attending the clinic had taken PEP at least once in the past two years and 25% had taken it between two and ten times in the previous two years. Unsurprisingly, there was a high level of interest in pre-exposure prophylaxis (PrEP): 42% of men expressed an interest in using it, but one-third of men knew nothing about it.
Hepatitis C was also highly prevalent among men attending the clinic: 12% of all men had tested positive for hepatitis C virus (HCV) at least once, and just over half of the men who tested positive for HCV were HIV-negative (52%). Twenty-nine per cent of all men attending the clinic said that they had injected drugs but 46% of all those attending the clinic who tested positive for HCV said that they had never injected drugs, indicating a high frequency of transmission through blood exposure during sexual activity.
Comment: This is a self-referring subset of men using the 56 Dean Street clinic who were explicitly concerned about their sex-on-drugs use, so they won’t be representative of clinic users, or London gay men in general. In a sense that does not matter: this is a snapshot of the most vulnerable gay men in the UK, the ones at what the iPrEx study called ‘imminent’ risk of HIV. Even within this sample, the study finds a subset at still higher risk: those newly diagnosed with HIV, who may also be among the minority not on HIV treatment, and whose outlier levels of risk and drug use may tell their own tale about mental health, crisis and the kind of support men may need at such times. What is needed now is a longitudinal survey of clinic users to establish how long these periods of risk are sustained, and what kind of prevention services would best meet needs at those times.
Modest bone loss seen in young men taking Truvada for PrEP
Participants in ATN 110, a pre-exposure prophylaxis (PrEP) demonstration project for young men aged 18-22, experienced modest but significant bone loss after starting Truvada, according to findings presented at the 15th European AIDS Conference. The tenofovir component of Truvada is considered to be generally safe and well-tolerated, but it is known to cause a small amount of bone loss in people taking it for HIV treatment – indeed another study presented at the conference confirmed that people starting HIV therapy lost about 2% of their bone mineral mass in the first year.
Bone mass generally peaks during early adulthood – typically around age 20 – after which it begins to gradually decline. Peak bone mass is an important predictor of fracture risk later in life so any reduction of bone mass in young people may be especially significant – and ATN 110 participants’ median age was 20.
Bone mineral density (BMD) levels were lower than expected at baseline, falling below norms for age and race/ethnicity; 8.1% of participants had spine BMD, 6.1% had hip BMD and 3.7% had whole body BMD below standard international thresholds for low bone mass. Six months after starting Truvada, bone density decreased at the spine (by about -0.2%), hip (by about -0.4%) and whole body (by about -0.8%), with the latter two changes being statistically significant. At 48 weeks, hip BMD continued to decrease steeply (falling by about -1.0%) and whole body BMD further decreased by a small amount, but spine BMD started to increase and in fact rose above the baseline level. However, adherence in ATN 110 declined over time, and by week 48 only about a third of participants still had highly protective drug levels. Bone loss at 48 weeks was correlated with tenofovir exposure. Men with highly protective tenofovir levels showed spine bone loss of about 1.5% at week 48, while those with undetectable drug levels saw their bone density rise by approximately the same amount.
Comment: It’s important not to get over-concerned about this study, as the bone loss observed – roughly in line with that seen in people on antiretroviral treatment – was not clinically significant or associated with fractures. Nonetheless, we need to be particularly alert to drug side-effects in a preventive medicine, especially as gay men starting PrEP in their teens may be on and off the drug for some years or throughout their lives. The best situation, of course, would be to do the studies to allow other drugs to be used as PrEP.
Hepatitis C stays constant among HIV-positive gay men in Europe; varies across regions
Researchers have seen no decline in new hepatitis C virus (HCV) infections among HIV-positive men who have sex with men (MSM) in 16 European cohorts, according to a presentation at the recent 15th European AIDS Conference. The analysis used data from nearly 6000 men in 16 of the 29 CASCADE cohorts of HIV seroconverters, or people with well-estimated dates of HIV infection. Cohorts were included if at least half the participating MSM had been tested for hepatitis C (HCV) using either antibody or HCV RNA tests. The incidence of HCV infection was calculated using two methods. Averaging the two methods, over a median follow-up period of four years, it is estimated that just over 300 infections happened. HCV annual incidence rose steadily, from roughly 0.15% a year in 1990 (one per 670 men a year) to roughly 2% a year (one in 50) in 2014.
HCV incidence trends differed by region. While new HCV infections still appear to be increasing in Southern Europe and Northern Europe, incidence in Western Europe seems to be stabilising. In a multivariate analysis, the likelihood of HCV infection was greater among men with a higher HIV viral load, though this study did not see a significant association with CD4 count.
Comment: It is interesting that this study spotted a quite significant association of hepatitis C infection and high HIV viral load: these were cohorts of men already living with HIV, so this is not because of simultaneous HIV and HCV infection. It could be caused by a third factor: periods of risk and vulnerability, as suggested in the chemsex study above, could feature both hepatitis C risk and poor ART adherence. It is possible that high levels of HIV in the body could make HCV infection easier through inflammatory processes. Whatever the cause, the risk of HCV infection in HIV-positive gay men is now roughly the same as the risk of HIV infection in HIV-negative men.
Other recent news headlines
EACS agree to treatment upon diagnosis and recommend daily or intermittent PrEP
The new European AIDS Clinical Society (EACS) HIV clinical guidelines, released at the 15th European AIDS Conference, bring Europe into line with the rest of the world by recommending HIV treatment upon diagnosis for all patients. The new guidelines also include a positive recommendation for pre-exposure prophylaxis (PrEP), which brings them into line with the US, WHO and BHIVA. PrEP is “recommended” for "men who have sex with men and transgender individuals, who are inconsistent in their use of condoms with casual partners or with HIV-positive partners who are not on treatment,” and “may be considered” for “heterosexual men and women who are inconsistent in their use of condoms and are likely to have HIV-positive partners who are not on treatment.” The guidelines recommend that PrEP can be prescribed as a daily or intermittent regimen, in the latter case taken as it was in the Ipergay study (a double dose in the 24 hours before sex, with a single dose on each of the following two days).
Why is injecting equipment re-used? Drug users do their own research to find out
Even in the context of the relatively good access to harm reduction services in Australia, the principle reasons for people who inject drugs to re-use syringes relate to the convenience of services, the stigma of drug use, a fear of repercussions and other contextual factors, the 24th International Harm Reduction Conference heard. A unique aspect of this study is that it was planned, conducted and analysed by peers of those being researched (current or former injecting drug users). As the research is both peer-led and qualitative, it can add the voice of people who use drugs to the question of why re-use of injecting equipment occurs.
Recent infection and ART interruptions are key periods for HIV transmission
A large proportion of HIV transmissions occur during recent infection or antiretroviral treatment interruptions, Swiss investigators report in Clinical Infectious Diseases. Overall, 44% of transmissions were associated with recent infection and 14% could be attributed to treatment interruptions. The authors believe these findings represent a major challenge for treatment as prevention (TasP) strategies.
Opioid substitution therapy reduces transmission of hepatitis C
A pooled analysis of 25 studies has shown for the first time good evidence that methadone and other forms of opioid substitution therapy (OST) in people who inject drugs substantially reduce new hepatitis C infections. Previously, this had been clearly demonstrated for HIV, but not hepatitis C. The meta-analysis showed that OST by itself reduced hepatitis C infections by 39%, and by 71% when coupled with high usage of needle exchange. This preventive effect has previously been proven for HIV but never for hepatitis C before.
Editors' picks from other sources
Ireland: Injection rooms for addicts to open next year, says Minister
from Irish Times
Drug users will be able to use supervised injecting rooms in Dublin next year, followed shortly afterwards by Cork, Galway and Limerick, according to the Minister in charge of the National Drugs Strategy. He also plans to decriminalise the possession of small amounts of drugs, including heroin, cocaine and cannabis, for personal use, as part of a “radical cultural shift” in the approach to drug addiction.
Long-acting injectable HIV treatment shows promise in early study results
from Science Speaks
A future of HIV treatment that doesn’t depend on daily dosing seemed to move a little closer today with an announcement that early findings show an injected combination of two antiretroviral medicines given monthly or every two months effective in controlling HIV among people whose virus was already suppressed. Studies looking at the injectable regimen as PrEP are also underway.
Study suggests unprecedented 3-week hepatitis C cure
from Science
Yet another stunning victory in the drug battle against the liver-damaging hepatitis C virus may be in the offing: A small study suggests it may be possible to cure some people of their infections in as few as 3 weeks.
In heroin crisis, white families seek gentler war on drugs
from New York Times
When the nation’s long-running war against drugs was defined by the crack epidemic and based in poor, predominantly black urban areas, the public response was defined by zero tolerance and stiff prison sentences. But today’s heroin crisis is different, affecting more white and middle-class people. Their families are now using their influence, anger and grief to cushion the country’s approach to drugs, prodding government to treat it not as a crime, but as a disease.
Why microbicides for HIV prevention are still necessary in the treatment-as-prevention era
from The Body Pro
How do things stand with the development of topical agents for HIV prevention? In the age of oral pre-exposure prophylaxis (PrEP) and treatment as prevention, does it matter anymore? And if lessons learned by researchers in the VOICE (Vaginal and Oral Interventions to Control the Epidemic) trial – discussed most often in terms of its failure – help make future HIV clinical trials more effective, can we really call it a failure?
Better organized HIV care could save lives and billions of dollars, computer model predicts
from Johns Hopkins Medicine
In a report on their HIV epidemic-economic model, published by the journal Clinical Infectious Diseases, the researchers say that efforts to encourage people with HIV to follow up regularly with their provider and maintain long-term drug therapy may be more fruitful in preventing HIV transmission than efforts to increase HIV testing alone.
Health minister warns Russia's HIV epidemic could spiral out of control
from The Moscow Times
Russia's HIV epidemic could spiral out of control by the end of the decade if treatment for the life-threatening virus is not expanded, the nation's health minister warned.