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 used condoms.

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 methods.

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.

HIV-negative 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 methods?

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 infection.

A ‘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.

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).

A 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.

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 organisation.

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 (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:

• Developing 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).
• Producing press adverts, web pages, online activities, posters and leaflets to support campaigns.
• Providing press and public relations support.
• Managing the administrative work of HPE (project management, financial management, materials distribution, etc.).
• Engaging 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.
• Co-ordinating National HIV Testing Week.
• Organising two conferences during the next three years.

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 UK.

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 campaign. 

“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.

Black gay men run higher risk of HIV infection despite fewer partners

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 >>

Condoms used in one-in-four heterosexual encounters in the US

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 >>

Contraceptive injections and HIV infection risk – a public health conundrum

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 >>

In resource-rich countries, migrants have a higher risk of progressing to AIDS in the first year of HIV therapy

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 >>