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How effective are condoms?
Although condoms are a cornerstone of HIV prevention, there are relatively few data on how effective they are at preventing infection.
Although many people believe them to be almost 100% effective, previous studies
have shown that during vaginal sex, condoms actually reduce the risk of
infection by around 80 or 85%.
There are fewer studies for anal sex. To fill the gap,
researchers presented a
new analysis of infection rates in gay men last week. As all men in the
study reported anal sex with an HIV-positive partner, they were at a
particularly high risk of being exposed to HIV.
Men who said they always
used condoms were 70% less likely to acquire HIV than men who never used condoms. The figures were the same for both insertive and
receptive anal sex.
The reasons why effectiveness is lower than 100% may include
incorrect use of condoms and men not noticing that a condom had broken or
slipped off. Also, some men may have told researchers that they had used a
condom, when this was not actually the case.
The study’s second finding was that men who sometimes used condoms were just as
likely to acquire HIV as men who never
One way of understanding this result is to consider the
accumulation of risk over time. If a man only uses condoms half the time – and
is frequently exposed to infectious HIV – then each sexual act without a condom
creates another occasion in which he is at risk of acquiring HIV.
It’s also worth noting that ‘sometimes’ users could be using
condoms as little as 1% of the time or as much as 99% of the time. The
researchers still need to do more detailed analyses to see whether there is a
threshold above which inconsistent condom use had some benefit.
Just one in six of the participants managed 100% condom use throughout the
three to four years they were in the study.
In the light of these results, HIV prevention organisations
and healthcare workers need to be more honest and more factual when talking
about condoms with clients. Discussions should acknowledge that no single
prevention method provides 100% protection. Also, the importance of consistent
use should be stressed.
Furthermore, the results underline the limitations of
condoms as a preventive method and the urgency of developing alternative
Disappointing PrEP and microbicide results
A large study of new prevention technologies for women in
South Africa, Zimbabwe and Uganda has found that none
of the methods reduced HIV infection rates – probably because the women were
not using the products regularly.
women (mostly in their twenties and unmarried) were randomised to use one of: a
daily pill of tenofovir; a daily pill of Truvada
(tenofovir + FTC); a placebo pill; a microbicide gel containing
tenofovir; or a placebo gel. Taking anti-HIV drugs to prevent infection in this
way is known as pre-exposure prophylaxis (PrEP).
Across all groups, HIV infection rates were equally high –
each year, 6% of women acquired HIV. In other words, none of the prevention
technologies made any difference.
Although women told their doctors that they were using the
pills or the microbicide gel, testing of drug levels in blood and vaginal fluid
showed that very few of them actually were. According to laboratory tests,
between 25 and 30% of women had any trace of the drug they had been given.
Adherence was especially low in the younger and unmarried women – precisely the
group who are at greatest risk of HIV infection in these countries.
The results are consistent with a previous study
of PrEP conducted with young African women which also found low adherence and
no difference in infection rates.
On the other hand, a
previous study which recruited HIV-negative people who were in a stable
heterosexual relationship with an HIV-positive person had much more encouraging
results. These African couples were generally older, adherence
was very high and PrEP was effective in reducing HIV infections.
It therefore seems that PrEP can be effective for some
people, but that it isn’t acceptable or feasible for young African women to
take it on a daily basis. It has been speculated that young women who feel
healthy may not be fully aware of their vulnerability to HIV.
In a very different context, researchers trying to provide
PrEP to young gay men in Chicago reported
this month that it was difficult to recruit young men into the study. And
those who took part had poor adherence, sometimes due to unstable lifestyles.
Because adherence is such a problem, researchers are
investigating other ways of delivering prevention drugs, especially methods that could be taken much less frequently. If women using contraception can
choose between a condom used at the time of sex, a pill taken every day, a
vaginal ring inserted once a month, an injection given every twelve weeks and
several other methods, why can’t there be a similar choice of HIV-prevention
Last week, researchers presented
early results from animal studies into new PrEP delivery methods. An
injection of a drug from the integrase inhibitor class repeatedly protected all
monkeys against infection. In humans, the injection might need to be given once
a month or once every three months.
And a ring containing tenofovir that was inserted into
monkeys’ vaginas once a month protected this group of animals against
Treatment as prevention
‘real world’ study from rural Uganda has provided more evidence of the
factors that affect HIV transmission, including HIV treatment. There were 259
married couples, where one partner had HIV and the other did not, in this
observational study. Each couple was followed for an average of three years.
Overall, the infection rate was high – each year, 7% of
HIV-negative partners acquired HIV (62 infections in all).
- Women were more likely than men to acquire HIV.
This is probably because biological differences make women more vulnerable when
exposed to HIV.
- Muslims were less likely than Christians to
acquire HIV – probably because male Muslims were circumcised, but male
Christians were not.
- When the person with HIV had a lower viral load,
their partner was less likely to acquire HIV. In fact, looking only at the 29
couples in which HIV treatment was taken, there were no infections at all.
This study adds to the evidence that, outside of the
idealised conditions of a randomised controlled trial, HIV treatment does
reduce onward transmission.
Menstrual cycle and HIV transmission
The quantity of HIV in genital fluids varies during the
menstrual cycle, according
to new research. The highest level (in other words, with increased risk of
HIV transmission) occurs around the time of a woman’s period (menses), and
declines until it reaches the lowest point around
the time of ovulation (on average, 14 days after the period).
During the remaining part of the
menstrual cycle, genital HIV levels remained steady for most women. However,
they increased for women with CD4 counts below 350 cells/ mm3.
The information comes from an analysis of Thai women who
were not taking anti-HIV drugs. Effective HIV treatment will lower quantities
of HIV in genital fluids.
This is likely to be useful information in answering
questions from women with HIV, especially those considering having unprotected
sex in order to conceive. It is reassuring that levels of HIV are lowest during
a woman’s fertile time (ovulation).
People with HIV not disclosing at GUM clinics
study from a London genitourinary medicine (GUM) clinic has found evidence
of people with HIV attending for a sexual health check-up but not disclosing
their HIV status. Two years ago, another
UK study had similar findings.
Non-disclosure may occur because some HIV-positive people
wish to avoid discussing their sexual behaviour with healthcare staff, or are
concerned about having such discussions recorded in medical notes, because of
fears around criminal prosecutions.
Blood samples that had originally been taken for syphilis
tests were anonymised and then tested for HIV antibodies. The clinic identified
samples from 18 individuals who had undiagnosed HIV and who had not taken an
HIV test during their consultation.
Further testing showed that 13 of the 18 individuals had an
undetectable or very low viral load – almost certainly because of HIV
treatment. Another set of tests (only conducted on 8 samples) found that all
had therapeutic levels of anti-HIV drugs.
This could mean that estimates of the proportion of
infections that are undiagnosed need to be adjusted.
In addition, people living with HIV need to be aware that, in some
cases, the tests and treatment offered for sexually transmitted infections are
different depending on the patient’s HIV status.
Prosecutions for transmission of HIV
Staff providing clinical, psychosocial and community support
for people with HIV would benefit from better information and support around
prosecutions for the sexual transmission of HIV, according to new research.
This UK study paints a picture of professionals grappling
with the difficulties of communicating complex legal information in an
appropriate way for each individual. They must weigh up competing concerns and
responsibilities, including their own patient’s health and wellbeing, the
health of unidentified sexual partners and the legal liability of their own
The authors make a number of recommendations about the
information, training and support that would help staff – who usually do not
have legal training – deal with this challenging topic. They recommend that
organisations have internal policies and procedures for staff to refer to,
perhaps adapting the recent position statement by the British HIV Association
(BHIVA) and the British Association for Sexual Health and HIV (BASHH), HIV
Transmission, the Law and the Work of the Clinical Team.
This document sets out the roles and responsibilities of
healthcare professionals when caring for people living with HIV, in relation to
sexual transmission of HIV and disclosure of HIV status.
Terrence Higgins Trust’s role in HIV Prevention England
Terrence Higgins Trust (THT) is the contract holder for HIV
Prevention England, the new national HIV prevention programme working with
African communities and men who have sex with men (MSM). The other five main
partners (profiled in previous bulletins) are BHA, MBARC, Yorkshire Mesmac,
Sigma Research and NAM.
Set up in
1982, Terrence Higgins Trust is the largest HIV and sexual health charity in
the UK. It also led the previous national HIV prevention programme for men who
have sex with men, CHAPS.
On behalf of HIV Prevention England, Terrence Higgins Trust
holds the contract and manages the relationship with the Department of Health.
Moreover, it has a number of other specific roles:
social marketing campaigns which aim to change perceptions of the value,
desirability and social norms relating to HIV testing and safer sex. In 2012,
the THIVK campaign was delivered and a new campaign will launch in spring 2013 (see below).
press adverts, web pages, online activities, posters and leaflets to support
press and public relations support.
the administrative work of HPE (project management, financial management,
materials distribution, etc.).
with key stakeholders in local authorities, health and wellbeing boards, the
British Association for Sexual Health and HIV, the British HIV Association,
large gay businesses and organisations, etc.
National HIV Testing Week.
two conferences during the next three years.
Next HPE campaign
In late April, HIV
Prevention England will launch a new health promotion campaign for men who have
sex with men and Africans in England. “It Starts With Me” will run for two years
and be one of the largest HIV prevention campaigns undertaken in the
The key messages
will encourage people to test for HIV regularly, to take HIV treatment if
appropriate (with benefits both for the individual and the wider community), to
adopt protective behaviours (condom use, monogamous relationships, fewer
partners, etc.) and to take action in support of the
“It Starts With Me”
will be rolled out through a co-ordinated network of community organisations
across England. Watch this space for more details, but for specific information
on ways your organisation can get involved, please email HPE@tht.org.uk.
Other recent news headlines
An analysis of four studies of sexual risk and HIV infection in US gay men, presented at the 20th Conference on Retroviruses and Opportunistic Infections (CROI 2013), has found a 22% higher risk of HIV infection per sexual contact in black gay men that is not explained by other factors such as number of sexual partners, injecting drug use or age. Read more >>
A quarter of heterosexual adults in the United States used a condom the last time they had vaginal sex, researchers from Indiana University have found. Respondents generally reported that condom use made no difference to sexual pleasure, to orgasm, or to maintaining an erection in men. Read more >>
The concerns about a possible increase in risk of HIV acquisition with some hormonal contraceptive methods need to be understood in the context of the substantial uncertainties in the body of evidence, and considered alongside the life-saving benefits of hormonal contraceptive use, Dr Chelsea Polis of USAID told the 20th Conference on Retroviruses and Opportunistic Infections. This “leaves us in a real public health conundrum”, she said. Read more >>
Rates of AIDS-defining illnesses in the first year of antiretroviral therapy are significantly higher among migrant than non-migrant populations in resource-rich countries, investigators report in the online edition of AIDS. The difference was mainly driven by higher rates of tuberculosis among migrant populations. The results show the importance of screening people for tuberculosis before commencing HIV therapy, say the investigators. Read more >>
Editors' picks from other sources
from The Guardian
There is already a way of preventing mother to child infections using drugs – which is far better than a functional cure using similar drugs. The excitement of the Mississippi case is in what it tells scientists trying to figure out how to cure HIV. Any practical applications are a long way further down the line.
from Positive Lite
Len Tooley is a 31-year old, sexually active, HIV-negative gay guy who is taking Truvada as pre-exposure prophylaxis (PrEP). In the third and final part of our interview, Len responds to those people in the gay and HIV communities who are critical of negative guys like him who decide PrEP is right for them, about why he decided to talk publicly about being on PrEP and what he would say to others who are considering this option as a way of staying HIV negative.
from CATIE Prevention in Focus
The concept of an HIV treatment cascade has emerged as a way to identify gaps in the continuum of care, which are preventing people from realizing the treatment and prevention benefits of antiretroviral therapy. This article takes a closer look at the treatment cascade in Canada, considering
the interventions that could make a difference there.
from Health Protection Agency
and incident management is a core element of sexual health
commissioning and this briefing provides information on recent incidents
across England and sets out recommendations for commissioners in local