European study shows that less education is associated with late diagnosis and treatment
Even in western European countries with universal access to health care, there are socioeconomic inequalities in timely access to HIV testing, a recent study finds. People with lower levels of education are more likely to be diagnosed with advanced HIV disease and to start HIV treatment with a low CD4 cell count.
Sara Lodi and colleagues therefore analysed cohort data from 15,414 people diagnosed with HIV in Austria, France, Greece, Italy, Spain and Switzerland between 1996 and 2011.
As a proxy measure of socioeconomic status, the researchers used educational level because it was the only indicator that was collected in several European countries in a standardised way. Individuals’ level of completed education was classified as uncompleted basic (generally, left school before 16); basic (generally, to 16); secondary (generally, schooling over the age of 16); and tertiary (degree or vocational courses).
Across the cohorts, while 73% of people with uncompleted basic education were diagnosed with a CD4 count under 350 cells/mm3, 55% of people with tertiary education were. Similarly 52% of people with uncompleted basic education were diagnosed with CD4 counts below 200 cells/mm3, only 31% with tertiary education were. The average CD4 counts on diagnosis in these two categories were 173 and 251 cells/mm3.
Comment: These results are perhaps no great surprise, but pan-European studies of the social aspects of HIV are relatively rare. Education, the researchers say, may mean people have better access to health care, monitor their own health more carefully, make better health choices and be more resilient to stigma and psychological factors like low self-efficacy.
PrEP will need high adherence, high effectiveness and high coverage in high-risk populations to be affordable
A study based on New York City that modelled pre-exposure prophylaxis (PrEP) uptake there has found that, in order to be affordable, PrEP would need to be tightly targeted at men who have sex with men (MSM) at higher risk of HIV. Within this target population, it would need high levels of usage.
A reduction in the price of Truvada – the tenofovir/emtricitabine combination pill which is currently the only one used for PrEP – would also help. The model ran through a number of scenarios and found that while PrEP could be potentially cost-effective at Truvada’s present price, it would only become cost-saving if its current US price was halved. Even then, it would require near-universal uptake in higher-risk gay men.
The model found no scenario in which PrEP was cost-effective if offered to high-risk heterosexuals, and almost none if it were offered to people who inject drugs.
The cost of PrEP offered to the general population would be vast, and completely uneconomical. If PrEP was offered to the entire HIV-negative population, the model predicts it would prevent 29% of all HIV infections at a cost of $52 billion a year per HIV infection averted. If given to all men who have sex with men, that would stop 19% of HIV infections overall and would cost $1.24 million per infection averted. But if targeted specifically at MSM having “multiple concurrent partnerships” this would cost $740,000 per lifetime infection averted at an annual net cost of $467 million a year.
If PrEP is modelled to be 75% effective rather than 44% – reflecting the higher adherence rates in US sites in the iPrEx study – then it could prevent 22% of HIV infections for the same cost and this would put PrEP within the realm of cost-effectiveness.
If the drug price was halved and coverage in high-risk gay men was as high as 70%, then PrEP would actually start saving money – the PrEP programme would cost less than a lifetime’s antiretroviral therapy for the HIV infections that would otherwise have happened.
The same modelling has not been done in the UK, but figures obtained by aidsmap.com show if PrEP was taken by 30% of gay men attending sexual health clinics who are diagnosed with an acute sexually transmitted infection (which is strongly associated with a high risk of subsequent HIV infection), then this would lead to a PrEP cost of no more than £38,000 per HIV infection averted and probably less if actual UK Truvada and healthcare costs are used. This is close to the generally used threshold for cost-effectiveness of £30,000.
Comment: PrEP can be cost-effective and even cost-saving in countries with high incomes and high drug prices, this model suggests. However, for this to happen, its use needs to be restricted to those most in need, adherence needs to be maintained and drug costs need to fall, probably considerably – which may be unlikely until 2017/2018 at the earliest, when tenofovir comes off patent.
Learning about additional HIV prevention methods doesn’t undermine gay men’s intentions to use condoms
The researchers conducted an experiment in which HIV-negative gay men watched videos about different prevention topics. Four HIV-prevention videos were developed, each one focusing solely on either condoms, PrEP (pre-exposure prophylaxis), PEP (post-exposure prophylaxis) or rectal microbicides. Study participants were randomised to see either a single video, a combination of two videos, or all four videos together.
Afterwards, the researchers asked men about their likelihood of using the prevention method(s) they had just been given information about. In addition, the respondents were asked about the advantages and disadvantages of sex with and without condoms. There were no significant differences in participants’ intention of using condoms, or their assessment of condoms’ costs and benefits, according to the videos that had been seen. This was also the case for intentions to use PEP, PrEP or rectal microbicides. Seeing information about additional options either made no difference to men’s intention to use a specific method (e.g. a microbicide), or it was associated with a greater intention to use them (PEP, PrEP).
The results were consistent for men who reported unprotected sex with casual partners, and men who did not.
“Our results are inconsistent with risk compensation theory, which posits that use of a biomedical prevention approach will lead to less positive attitudes, intentions, and use of condoms,” comment the authors.
Comment: One has to be very cautious about any study that asks respondents about their intention to use condoms (or other HIV prevention method) due to social desirability bias. In addition, intention to use is not the same as use. However it does show that giving gay men information about a range of methods can inform without being confusing.
Expanded harm reduction in Scotland achieves impressive drop in hepatitis C among people who inject drugs
Implementation of comprehensive harm reduction policies in 2008 has achieved impressive reductions in the incidence of hepatitis C infections among people who inject drugs in Scotland. Incidence of hepatitis C among people who inject drugs declined sharply between 2008 and 2012 and the investigators estimated that the harm reduction interventions averted 1000 new chronic hepatitis C infections in this population.
In 2008, the Scottish government introduced a comprehensive programme of harm reduction interventions to prevent hepatitis C infections among people who inject drugs. The programme included the distribution of sterile injecting packs including filters and spoons as well as needles and syringes and also improvements in opioid substitution therapy.
A team of investigators designed a study to examine the impact of these interventions on hepatitis C infection rates among people who inject drugs between 2008 and 2012. They recruited a total of 8000 people to three separate cross-sectional studies. There were 53 incident hepatitis C infections. The incidence rate declined from 13.6 per 100 person-years in 2008/9 to 7.3 per 100 person-years in 2011/12. The authors estimate that 1400 new infections, 1000 of which would have become chronic, were averted by the scale-up of harm reduction between 2008 and 2012.
This drop in incidence was accompanied by an increase in the proportion of people receiving opioid substitution therapy (from 50 to 64% in the same period) and declines in the proportion reporting needle sharing (from 15 to 8%), and the proportion reporting daily injecting (from 63 to 49%).
Comment: Another encouraging but not unexpected finding, given the known efficacy of comprehensive harm reduction in HIV prevention. Not enough research is done in this field however and, as the researchers say themselves, “This is in fact the first study to demonstrate that impressive reductions in HCV incidence can be achieved among people who inject drugs over a relatively short period through high coverage of a combination of interventions.”
Novel immune-suppressant vaccine completely blocks HIV infection in monkeys: human trials planned
The vaccine appears to work by stimulating the production of a previously unknown group of CD8 T-cells that, while recognising SIV themselves as a foreign invader, actively prevented the monkeys’ CD4 cells from recognising it, thereby preventing an immune response to SIV. This suppressant effect works in the opposite way to a traditional vaccine by suppressing rather than stimulating the body’s response to HIV infection. The scientists reasoned that this would stop the proliferation of the cells HIV needs to use for replication and thus ‘starve’ an infection at its root.
The vaccine consisted of inactivated SIV administered alongside doses of familiar bacteria – in the most effective versions, gut bacteria of the Lactobacillus genus, including one type commonly used in probiotic supplements. This suggests that if human studies replicate the success seen in monkeys, the vaccine could be administered in a drink.
So far 15 of the 29 monkeys have been completely protected from SIV infection. Only one monkey given the vaccine as an oral formulation, and who also received SIV rectally, could be infected, despite repeated challenge – and that monkey only lost its immunity to SIV a year after vaccination. All the others still appear immune to SIV four years after vaccination.
Two initial safety trials are now planned in humans. In one, HIV-negative volunteers at low risk of HIV will be given the vaccine to see if it stimulates the same immune- and virus-suppressant responses. In the other, volunteers living with HIV who are on fully suppressive antiretroviral therapy (ART) will be given the vaccine and then taken off ART six months later if test tube results suggest the vaccine has produced such responses.
Comment: These very impressive results were described by the researchers themselves as ‘surprising’ and ‘unexpected’. We have learned from studies such as STEP that promising immune reactions to HIV vaccines seen in animals are not always reproduced in human trials. But the premise – that, because HIV infects the very cells normally stimulated by a vaccine, an HIV vaccine would need to do the opposite and calm them down – makes sense; something similar may work in apes and monkeys that carry SIV without disease. There is much to explain, including why an ineffective killed-virus vaccine suddenly becomes effective when given with a simple probiotic supplement, but even if human trials work less well, this opens up an intriguing new line of vaccine research.
HIV testing rates are improving in African people in England
A survey of African people living in England suggests that the proportion of people who have recently tested for HIV has increased over the last five years, since the last comparable survey. There are also improvements in people’s knowledge about HIV testing and treatment.
The survey recruited1026 African people, 62% of them women, who were living in England. They completed an online survey that was promoted through targeted Facebook advertising, community-based organisations and additional online advertising. Over half the respondents completed the survey on a smartphone or tablet.
In the most recent data, two-thirds of respondents had ever been tested for HIV, including one in nine who had been diagnosed with HIV. While one third had never tested for HIV, this figure appears to have dropped since the last survey, five years ago. There was a 50% improvement in the proportion who had recently tested, compared to the previous survey. Those with lower education had the lowest rates of testing (half had never tested) but one-third had tested HIV positive.
While HIV testing as a part of regular health screening is promoted by public health bodies, it was a reason to test for 30.4% of those receiving a negative result, but only 11% of those being diagnosed with HIV. People who were HIV-positive had more commonly been tested because they were ill (34%) or because a doctor had suggested it (13%).
There is one important knowledge indicator which has worse results than five years ago. In the current survey, 72.7% of respondents did not know that 1 in 20 Africans in the UK have HIV, a statistically significant increase on the previous survey.
Comment: These are encouraging results. In the more qualitative part of the survey, respondents expressed a preference to get tested at their GPs rather than at a sexual health clinic – especially people who had never tested. This is promising as it suggests fears about confidentiality and disclosure by GPs may be ebbing.
Gay men in London getting younger at diagnosis
The study estimates that 3.8% of adult male Londoners are gay or bisexual (men who have sex with men, MSM) but that MSM constituted 24% of all London residents diagnosed with a sexually transmitted infection (STI) last year, 65% of those diagnosed with syphilis and 84% diagnosed with gonorrhoea and that the number of those diagnoses was increasing. Outbreaks of lymphogranuloma venereum (LGV), shigella and sexually transmitted hepatitis C have occurred almost exclusively in gay men too and have been concentrated in certain London boroughs.
Similarly, 51% of new HIV diagnoses in London are in men who have sex with men. There were 1451 diagnoses among MSM in London in 2012, which represents a 28% increase compared to 2003. Whereas it is estimated that across the United Kingdom one in 34 gay men is living with HIV, the comparable figure for London gay men is one in twelve.
“The factors behind the worsening of sexual health in MSM are complex and represent a challenge to tackle,” say Public Health England. They recommend a continued emphasis on expanding opportunities to test for HIV and increasing the frequency with which men test. Condoms should also to be provided “at scale”, backed up with strong communications.
Comment: As we note in our news story, a discussion of the potential of pre-exposure prophylaxis (PrEP) is notable by its absence in this report. The other notable fact is that 60% of MSM in London newly diagnosed with HIV are born abroad: yet there seems little coherent strategy so far to develop resources that address the needs of MSM new to London, such as multi-language HIV publications. The fall at the average age at diagnosis may not be a bad thing if it is a result of young gay men testing more, and it is very important to emphasise that increased HIV diagnoses may be due to more HIV testing, not more infections: in fact the latest surveys of actual incidence appear to show a steady state, with neither increase nor decrease in the actual annual number of infections. However, as long as this is the case, the prevalence of HIV in MSM in London is only likely to increase.
Other recent news headlines
Drug use strongly associated with sex, condomless sex and STIs in gay men living with HIV in England
A large survey of gay and bisexual men living with HIV and attending eight sexual health clinics in England has found that half of them had used recreational drugs in the last three months and a quarter had used more than three drugs. The study found strong associations between drug use – and the number of different drugs used – and sex, condomless sex, group sex, and diagnosis with a sexually transmitted infection. However, it found that only a minority (7%) had sex with high HIV infection risk.
Stigma, ambivalence and other priorities – explaining poor adherence to PrEP and vaginal microbicides
HIV stigma, fear of being mistakenly labelled as having HIV, ambivalence about the research process, confusion about the use of antiretrovirals to prevent infection, and balancing trial participation with other priorities, all shaped South African women’s experience of using pre-exposure prophylaxis (PrEP) or a microbicide gel within the VOICE clinical trial, according to a qualitative study. The researchers sought to better understand the reasons for the disappointing results of the VOICE trial. The findings are very similar to those from the similarly disappointing FEM-PrEP trial, including the finding that many participants signed on in order to get better clinical monitoring rather than due to an interest in volunteering for research.
HIV prevention for black African people in the UK is under-resourced and needs to be scaled up
The National AIDS Trust (NAT) argues in a recent report that although black African communities in the UK are disproportionately affected by HIV, “the HIV-related needs of black African communities receive neither the attention nor the resources they should from policy-makers, decision-makers and funders.” In particular, NAT believes that appropriate HIV prevention needs to be scaled up, but in a way which avoids black African people feeling “targeted” or “singled out” as a risk group for HIV infection.
Editors' picks from other sources
Trust, intimacy, and HIV testing
from BETA blog
A recent US study finds that partnered men who have sex with men (MSM) are significantly less likely to have regular HIV tests than MSM who are single. Among a sample of 404 partnered HIV-negative men, less than half (49%) reported getting tested at least once a year. Partnered MSM are also much more likely than single MSM to engage in anal intercourse without condoms. Estimates show that as many as three-quarters of HIV infections among MSM in the US happen in the context of primary relationships.
How did 'the Berlin patient' become cured of HIV?
from Washington Post
Researchers are closer to unravelling the mystery of how Timothy Ray Brown, the only person cured of HIV, defeated the virus, according to a new study. Although the work doesn't provide a definitive answer, it rules out one possible explanation. The chemotherapy that wiped out the majority of his HIV-infected cells would not have been sufficient in itself, researchers argue: in addition, a process seems to have happened where HIV-immune cells that were replaced within a bone marrow transplant actively out-competed and killed off any remaining HIV-infected cells.
Advocates applaud launch of MTN-017, world’s first phase II rectal microbicide study
IRMA applauds the launch of the world’s first-ever phase II rectal microbicide trial. The Microbicide Trial Network’s study, called MTN-017, will test a reduced glycerin formulation of tenofovir gel applied rectally. Volunteers consisting of gay men, other men who have sex with men, and transgender women will participate in the study at sites in the United States and in Thailand, South Africa, and Peru.
Minsk has extremely high levels of drug-resistant TB, a study in Belarus reveals
from the TB Europe Coalition
A survey in Minsk, capital of Belarus, has found that nearly one in two patients diagnosed with tuberculosis had the multidrug-resistant form of the disease (MDR-TB). The findings are alarming as they represent the highest proportion of MDR-TB ever recorded in the world. MDR-TB was found in 35% of new patients and 77% of those previously treated. Extensively drug-resistant TB (XDR-TB), which is extremely difficult to treat, was found in 15 of the 107 MDR-TB patients (14%).
HIV pandemic originated in Kinshasa in the 1920s, say scientists
from The Guardian
A “perfect storm” of urban change that began in 1920s Kinshasa led to the catastrophic spread of HIV across Africa and into the wider world, according to scientists who used genetic sequencing and historical records to trace the origins of the pandemic. Though the virus probably crossed from chimpanzees to humans in southern Cameroon years earlier, HIV remained a regional infection until it entered the capital of what is now the Democratic Republic of the Congo.
New York City promotes acceptance of controversial HIV drug
from Newsday
New York City's health department is advertising on gay hook-up apps and lobbying doctors to promote wider use of a controversial anti-HIV pill that vastly cuts the risk of infection. But the therapy has stoked infighting among AIDS activists over promiscuity and safer sex practices.
Selling the End of AIDS
from Poz
As slogans anticipating an end to the AIDS epidemic gain popularity, sceptics worry that such promises are hollow and unrealistically ambitious, and that failure to deliver will ultimately set back efforts to combat HIV.
Can this HIV drug help to end 30 years of blighted lives?
from The Guardian
Columnist Owen Jones says that Truvada is giving peace of mind to gay men in the US and should be offered in the UK on the NHS now.