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Important changes to HIV-related rules announced by Department of Health
Legal barrier to self-testing in the UK lifted
The Department of Health announced
an important change to HIV testing policy for the United Kingdom this week.
From April 2014, HIV self-testing kits approved by the Medicines and Healthcare
Regulatory Authority will be available for sale to the public.
Any device designed for home testing will
be required to carry the CE mark, which indicates that it conforms to minimum
European standards regarding sensitivity and specificity (see here
for further details of these standards).
for self-testing has been welcomed by HIV organisations, although concerns are
frequently expressed regarding the potential for failed linkage to care after a
published systematic review of studies on self-testing found it to be
acceptable across a wide variety of populations, but identified few data on
linkage to care after testing positive.
of Health said in its press statement: “If a test indicates a positive result
people are advised to get a follow-up confirmatory test at an NHS clinic. Clear
information about how to interpret the result and what to do afterwards will be
included with the kit.”
Dr Richard Ma, Sexual
Health lead for the Royal College of General Practitioners, said
that GP practices should also prepare for patients seeking a confirmatory test
after receiving a positive result on a home test.
At present, the only device specifically
designed for home testing and approved by a stringent regulatory authority is
the Orasure OraQuick HIV antibody
test, licensed in the United States in April 2013. This test samples fluid from
the gums on a swab. The swab is then placed in a tube of solution and will give
a visual result 20 minutes later. (A video showing how the testing process works
can be viewed
In practice, this test can already be
ordered online for purchase from US vendors for around £25. How much this test
will cost and when it will be marketed in the United Kingdom are still unknown.
Contrary to reports in The Independent
newspaper there is no commitment at present to make self-testing kits available
free through the NHS, the Department of Health told NAM.
Home-sampling kits supplied by Terrence Higgins Trust and Public Health England have
been available since January 2013 for gay men and Africans living in
England. Approximately 9000 people have requested the kits to date.
Mortimer Market Centre, one of London’s largest sexual health clinics, is due
to begin distribution of home-sampling kits to gay and bisexual men leaving
clubs in the Vauxhall area of south London from the August bank holiday
care workers with HIV and medical procedures
The Department of Health also announced
that healthcare workers with HIV will no longer be barred from carrying out
some surgical and dental procedures – provided that they are on treatment, have
an undetectable viral load, and receive regular medical monitoring.
Rectal STIs predict HIV infection
study from New York has found that a diagnosis of rectal gonorrhoea or
chlamydia is strongly associated with subsequent HIV infection, regardless of
sexual risk behaviour.
The study found that
between two and three times as many HIV-negative men diagnosed with rectal
gonorrhoea or chlamydia became HIV positive over the following year as men with
identical levels of condom use who did not have one of the two STIs.
This study’s findings
are similar to a
European one that found a strong association between STIs and HIV diagnosis in
2011. The European study,
however, looked at all STIs rather than rectal ones alone, and it found an
association between having an STI and already
having undiagnosed HIV, whereas the New York study found that a rectal STI predicted
subsequent HIV infection.
In the present study,
276 HIV-negative gay men attending a clinic in New York, who were diagnosed with
one of the two rectal STIs between 2008 and 2010, were followed for at least
one year to see how many then acquired HIV.
Sixty-nine per cent of
these men reported no condom use or inconsistent use, and the investigators
selected a comparison group of men who had identical levels of sex without
condoms but no rectal STIs.
During the course of the
following year, 11% of the men with rectal STIs acquired HIV compared with 4%
of those without rectal STIs – 2.6 times as many.
One important aspect of
the study was that 70% of the rectal infections detected were asymptomatic and
would not have been detected had participants not attended for a routine STI check-up.
Diagnosis of any acute
STI should automatically trigger a recommendation of an HIV test. Given the
strong association with subsequent HIV infection, rectal STIs could also in the
future serve as triggers for an offer of pre-exposure prophylaxis (PrEP) or
other intensified prevention measures.
What will it take for treatment to work as prevention?
health officials, donors, epidemiologists, researchers and clinicians need to
factor in the relevance of people’s social circumstances and cultural beliefs
if they are to see biomedical HIV prevention strategies – including treatment
as prevention (TasP) and pre-exposure prophylaxis (PrEP) – succeed in
real-world settings, speakers told the 2nd
International Conference for the Social Sciences and Humanities in HIV, held
recently in Paris.
is a simple acronym that masks considerable complexity,” commented Professor
Gary Dowsett of La Trobe University in Melbourne, Australia.
Although modelling studies have shown that - in theory -
programmes of testing and treatment could eliminate some countries’ HIV
epidemics, in practice a whole number of conditions have to be satisfied, said
Dowsett. These are as follows.
Large numbers of people who are at
risk of HIV infection:
- need to understand that they are
personally at risk;
- need to find the idea of testing
for HIV acceptable;
- need trusted, convenient and
affordable HIV testing services;
- and need to be willing to test
repeatedly, perhaps once every year or more.
diagnosed with HIV:
time to come to terms with the result;
to believe that there are benefits to engaging with health services now, even
though they may not feel ill;
to stay in touch with their doctors and nurses, which may mean overcoming
barriers that may have made it hard for them to attend a clinic in the first
advised to start HIV treatment, or contemplating it:
to believe that it will benefit them personally;
- or need to
understand the possible advantage for a sexual partner and consider this a good
enough reason to take the drugs;
- and need
to feel that perceived or actual problems such as side-effects or other people
finding out their HIV status are manageable in comparison with the advantages.
these, trusted, convenient and affordable health services need to be available.
efficient healthcare system is needed to provide the drugs, in a way that is
affordable for the patient, without interruptions in drug supply.
anti-HIV drugs need to be available in case of treatment failure.
- And all
these things need to happen, not just for a short period of time when the
conditions are favourable, but for decades.
For all these reasons, Professor
Susan Kippax, conference co-chair, argued that we cannot expect to see similar
results to HPTN 052 (the study which found that HIV
treatment reduced the risk of passing on HIV to a regular partner by 96%) when
early HIV treatment is used a population strategy.
“Some of the biomedics seem to fail to
understand that people live in cultural and social worlds,” she said.
“Populations are likely to differ from one another and may respond very
differently from one another.”
great diversity of results seen in trials of PrEP (from 73% reduction in risk
in one trial to having no effect in two others) suggests the importance of
attending to the social and cultural.
Marsha Rosengarten, another conference co-chair, summed it up by saying that
the conference’s key message was that “biomedical technologies do not – in and of themselves – prevent
transmission of the virus”.
We should provide HPV vaccine to young gay men, UK experts say
is a strong argument for extending the UK vaccination programme against the
human papillomavirus (HPV) to young
gay men, say a group of sexual health physicians. HPV vaccination is not currently recommended specifically
for gay men in the UK.
writers argue that this should change. Immunisation would be of benefit to the
vast majority of sexually experienced younger gay men, they say.
infection with high-risk strains of HPV (especially types 16 and 18) can lead
to the cancer of the cervix or anus. Gay men have high levels of HPV infection
and, in those with HIV, immune suppression can cause it to persist for longer. As
a result, cervical and anal cancers
are much more common in gay men and people with HIV.
UK HPV vaccine programme has prioritised adolescent girls because people tend
to start acquiring HPV infections soon after they start sex and the theory has
been that ‘herd immunity’ (a form of immunity when the vaccination
of a significant portion of a population provides
a measure of protection for individuals who have not developed immunity) would
also benefit boys. This has been partially borne out by data from Australia’s national
HPV vaccination programme.
Australia extended its HPV vaccination scheme to include school-aged boys after
data from the state of Victoria showed that HPV
infections had fallen dramatically in young heterosexual men and women, but not
in gay men.
The US Centers for Disease Control and Prevention also now recommends universal
vaccination for boys aged 11 and 12, and for gay men up to the age of 26.
in gay men have shown that Gardasil, the vaccine used in the UK school
programme, is very effective at preventing HPV infection with types 16 and 18
and offers significant protection against some other cancer-causing types. The
vaccine is most effective in people without any current HPV infection but has
acceptable levels of efficacy in individuals with existing HPV 16 or 18 infections.
One recent study found that although HPV 16 and 18 are very common in gay men
with HIV, vaccination by Gardasil could
prevent as many as 20% of them acquiring new infections per year.
The UK's Joint Committee on Vaccination and
Immunisation will decide whether vaccination of gay men under 27 is
cost-effective in 2014.
European women with HIV having unnecessary caesareans
are “missed opportunities” for HIV-positive pregnant women with a suppressed
viral load to give birth vaginally, European research shows.
in Europe recommend or permit a vaginal delivery when a woman has an
undetectable or very low viral load. However, investigators found that over a
third of women with viral suppression and no other contraindications continue
to have a caesarean section.
of vaginal deliveries were lower than expected,” comment the authors. “Our
results suggest that the policy for vaginal delivery among women among women
with undetectable or very low VL [viral load] is only slowly becoming
established within practice over time.”
elective caesarean section was recommended for HIV-positive women in 1999, but
the widespread use of antiretroviral therapy (ART) has reduced the risk of
mother-to-child transmission dramatically, with rates of below 1% seen across
Europe. Guidelines have been changed over the last decade to recommend that
women with very low viral loads aim for a vaginal birth. The additional
benefits of an elective caesarean section are open to question, especially as
the procedure can also involve risks.
collected between 2000 and 2010 from 3013 deliveries to 2663 women were
available for analysis.
8% of mothers did not receive ART during pregnancy or delivery and the
proportion of women taking ART who achieved a viral load below 400 copies/ml at
the time of delivery increased from 83 to 95% (87% of all the women) after the
new guidelines were in place.
However, after the
change in guidelines, the proportion of women giving birth vaginally only increased
from 17 to 52% and the proportion of vaginal deliveries in women with viral
loads under 50 copies/ml was actually lower, at 45%. For a third of the remaining
women, there was another reason for having a caesarean, but in 35% of cases the
woman could have aimed for a vaginal delivery.
Hepatitis C uncommon in HIV-negative gay men – unless they also have syphilis
was no evidence of a hepatitis C epidemic among HIV-negative gay men in London,
according to a community survey done in 2008 but only just published. It
found that only 1% of HIV-negative gay men in London had antibodies to the hepatitis
C virus (HCV) in 2008. This prevalence was “not significantly higher than in
the general population”, the authors comment. In HIV-positive gay men, however,
8% had antibodies to HCV.
other risk factors were associated with HCV infection. Prevalence of HCV was four
times higher among HIV-positive or negative men reporting unprotected sex with
a casual partner.
with antibodies to syphilis were over 12 times more likely to have HCV than men
Gay Men’s Sexual Health Survey (GMSHS) recruited 1121 gay men in community
settings such as gay bars, clubs and saunas. Fifteen per cent of them had HIV
and 12% had antibodies to syphilis (which may represent a current or former
is unlikely that HCV prevalence among HIV-negative gay men has increased
substantially since 2008. According to the recently
published Public Health England report Hepatitis C in the UK,
incidence of hepatitis C in HIV-positive men has declined significantly since
2008, to 2.2 new infections per thousand person-years of follow-up in 2012, and
there is no reason to expect a different trend in HIV-negative gay men. Another
that HCV prevalence in HIV-negative gay men was not statistically different
from prevalence in heterosexual men.
authors conclude that there is no reason routinely to test HIV-negative gay men
for HCV, but only to do so on the basis of risk.
One limitation of the study was that it did not
enquire about injecting drug use. Some doctors now believe that a proportion of
the HCV infections among HIV-positive gay men attributed to sexual transmission
may in fact be a consequence of sharing injecting equipment. Last month, a study
found a high rate of HCV re-infection in HIV-positive gay men who had been
successfully treated for the virus.
Other recent news headlines
pregnant, for women with HIV, is too often a state
of “social surveillance, monitoring, interrogation and criminalisation”,
according to Canadian researcher Sarah Greene. She told the 2nd
International Conference for the Social Sciences and Humanities in HIV that
healthcare practice needed to move to a situation in which mothering with HIV
is normalised, accepted, and left alone. Women feel that they are not only
under the gaze of medical professionals and child protection officials, but
also friends and family, who may take a particular interest in women’s infant-feeding
choices, she added.
We do not yet have sufficiently strong evidence to
recommend that antiretroviral treatment (ART) should be offered to all people
with HIV, regardless of their CD4 count, a group of clinical and community writers
has concluded. They criticise the current inconsistency between various HIV
treatment guidelines on when to start ART and add that if all guidelines used a
rigorous standard for rating evidence, their recommendations would be more
consistent and probably more cautious. Universal treatment upon diagnosis,
which two US guidelines now recommend, has been suggested as a way of
controlling the HIV epidemic.
A study in Malawi presented to the 2nd International Conference for the Social Sciences
and Humanities in HIV is offering glimpses into why couples choose HIV
self-testing. The researchers found that participants opted for self-testing
for a number of reasons, including risk behaviour, mistrust within the couple,
and a desire to either confirm an earlier HIV test result or check the
effectiveness of local 'faith healing'. The World Health Organization is
working to develop guidelines on HIV self-testing following the first-ever WHO
meeting on the subject in April 2013.
Editors' picks from other sources
from Sky News
Officials plan to revoke
legislation which bans on-the-spot testing kits in a drive to reduce HIV
infection rates. Under the HIV
Testing Kits and Services Regulations 1992, it is currently illegal to sell
kits which offer on-the-spot HIV results in the UK. But officials plan to change
the law so people can perform a saliva test at home to quickly give a
result. Public Health Minister Anna Soubry
said: "I hope that by removing the ban on self-testing kits people
will be able to choose the right time and right surroundings to take a
test and, if positive, help them get the best treatment available."
from Huffington Post UK
HIV Consultant Dr Steve
Taylor found that he faced an uphill battle when seeking ethics committee
permission to start routine, opt-out testing for HIV and hepatitis B and C in
the medical admissions unit of his hospital. “It has been shown that, whenever a healthcare
professional applies their clinical judgement as to whether an individual
requires an HIV test, testing rates fall by over 50%. This tells us that tests
should be routine. It tells us that we have to step away from the prejudices
and lack of awareness of healthcare professionals. We simply have to make the
test part of the wider package of care. ‘But what happens,’ yet another
committee member chipped in, ‘if that test finds someone to be HIV positive?’ A
long silence follows. "Then we would have saved that person's life,"
from IRIN Plus News
Gaps in mental health care
for men who have sex with men (MSM), a population disproportionately affected
globally by HIV, are limiting effective treatment and care for both HIV and
mental illness. “Mental health problems are an underappreciated barrier to
successful treatment and prevention of HIV, and this is doubly true in
low-income countries, and even more so for marginalised populations who are
dealing with layers of stigma,” says Brian Pence, an epidemiologist at the
University of North Carolina. A 2012 global survey by the Men Who Have Sex with
Men Global Forum (MSMGF), a US-based advocacy group, identified competent
mental health care as a key aspect of successfully getting MSM to access HIV
from Information Daily
Monty Moncrieff, Chief
Executive of London Friend, asks whether we on the verge of a new public health
crisis for the gay community. “Last week we saw the second report in six months
… on the link between new HIV infections and the use of ‘party’ drugs. New HIV
infections amongst men who have sex with men (MSM) in London are up more than
20% on last year, a trend we’ve feared based on the MSM accessing our
specialist support service Antidote for support around their drug use. It’s
another example of health inequalities for people of different sexual orientations
and/or gender identities,” he says. “The LGBT third sector receives only 0.03%
of all voluntary community organisation funding, a massive under-investment in
a population that even the most conservative estimates place at around three
million people in the UK.”
from The Guardian
Senthorun Raj writes on how the gay men’s phone
cruising app Grindr can lead to an exhausting search for intimacy: “It probably
comes as no surprise that many Grindr users have deleted and reinstalled the
application several times. With the labour and time demands of talking to so
many people, Grindr becomes an intimate commitment of its own. Then, of course,
there is the anxiety over finding ways to limit (or not) how you use it. Do you
continue to use it when you have a monogamous partner? How do you express your
desires in ways that do not marginalise others? Do you keep searching for more
and more people to talk to, or do you invest time in cultivating attachments to
those you have already formed a connection with?”