September 2015

No HIV infections seen in San Francisco PrEP users referred via primary care

A programme that provides pre-exposure prophylaxis (PrEP) through primary care referrals in San Francisco has not seen a single HIV infection in people using PrEP since it started in 2012. This is despite high levels of sexually transmitted infections (STIs) other than HIV and, in about 40% of users, less use of condoms. A total of 657 people started taking PrEP out of 1045 referred to the programme by their primary care physician, and the referral rate is accelerating, with the majority occurring in the last year.

In an editorial on the findings of the study, researchers Kimberley Koester and Bob Grant, who was principal investigator of the pioneering iPrEx PrEP study, comment that it is important to keep one’s eyes on the main prize – no new HIV infections – as “an expected and most desired outcome”. However, they note, it is also “Time for a vigorous conversation about sexually transmitted infections, too long eclipsed by fear of HIV infection.” They suggest that PrEP may offer more opportunities both within clinics and within the community to discuss and test for other STIs.

Comment: Despite all the caveats about reduced condom use and high STI rates (though, without a baseline comparison, we do not know if these have increased) this is a remarkable result, demonstrating 100% effectiveness for PrEP, in a ‘real world’ community setting, in those who start it. This should calm concerns that as PrEP usage spreads, adherence and effectiveness rates will fall. The increased concern about other STIs is entirely justified, but is a measure of how successfully PrEP appears to be at dealing with HIV infection.

Spanish pharmacy HIV testing programme detects many new infections

A programme in which cheap, 30-minute HIV tests were offered in 110 local pharmacy shops in three Spanish regions, diagnosed over 200 new infections. This amounts to one in nine of all HIV diagnoses in the three regions during the study period. Most of the heterosexual men diagnosed in the study had not had an HIV test before. The proportion of heterosexual men who had HIV was higher in those who had never tested than those who had. The HIV prevalence found in gay men was 40% higher than regional estimates.

There were particularly high rates of previously-untested people, diagnoses in men, and diagnoses in young people, in the rural and sparsely populated region of Castilla y León. Across the three regions, one in every 29 gay men and one in 200 heterosexual people who tested had HIV. In women, HIV prevalence was double the average in the Catalonia region, which includes a high proportion of immigrants. HIV prevalence was three times higher in people born in Latin America than in people born in Spain.

Comment: This is by far the largest pharmacy-based HIV testing programme ever undertaken and it is reassuring that acceptance in local communities appears high. In Spain pharmacies are usually small family-run businesses with local catchment areas and may be people’s most common way to interact with healthcare providers. As the authors comment, pharmacy-based testing offers a particularly valuable addition to other testing programmes, at least in the Spanish context, and may be particularly suitable in areas without large cities and with no specific HIV testing services.

HIV diagnosis rate high in Dutch STI clinics, but missed opportunities for diagnosis in primary care

Two studies from the Netherlands show that while the proportion of people with HIV who are diagnosed has improved in recent years, the Netherlands lags behind some other western European countries in its HIV diagnosis rate, which has not improved at all in some groups.

Diagnosis rates in people attending sexual health clinics were high in men who have sex with men (MSM) only 14% of whom, it is estimated, are undiagnosed. Rates were also high in non-migrant heterosexual people (16% undiagnosed). But they were considerably lower among MSM who did not visit sexual health clinics (35% undiagnosed), among African migrants visiting sexual health clinics (46% undiagnosed) and among migrants who did not visit sexual health clinics (about 50% undiagnosed).

A second study, of people attending six primary care practices in Amsterdam, found that the majority of people eventually diagnosed with HIV had attended their GP more than once in the year before their diagnosis and had more appointments and blood tests than a control group of matched patients who were not living with HIV. They were also vastly more likely than patients who did not test HIV-positive to have been diagnosed with a sexually transmitted infection (STI) or at least one of a list of HIV-related diseases and symptoms. The most common single condition associated with subsequent HIV diagnosis was unexplained weight loss.

Comment: These results are not dissimilar to those from other western European countries, although the proportion of people whose HIV is undiagnosed, and who do not get STI check-ups, is higher than in countries such as France and the UK. Given that many people with HIV have no reason to visit an STI clinic or may prefer seeing their GP, it is vital for primary care physicians to receive better training and good national guidelines on indicator conditions for HIV.

Sexual transmission of HCV is increasing among gay and bisexual men with HIV

Sexual transmission of hepatitis C virus (HCV) is occurring among HIV-positive men who have sex with men (MSM), associated with receptive anal sex and non-injection drug use, a recent analysis of studies finds. It also found that a small subset of men may be prone to recurrent infection after being cured of hepatitis C

If one thousand HIV-positive MSM were followed for one year each, the researchers found, approximately five would acquire HCV – in other words an annual incidence of 0.5%. This is far lower than the rates among people who inject drugs, and lower than HIV incidence in HIV-negative gay men. But the researchers saw an increase in recent years; incidence rose from 0.42% a year in 1991 to 1.34% in 2012. The analysis also showed that the re-infection rate for MSM living with HIV following successful HCV treatment was 20 times higher, with an annual incidence in the region of 12-16% – within the range seen in people who inject drugs. HCV was primarily associated with condomless receptive anal sex, 'traumatic' sex that could cause rectal mucosal damage or bleeding, fisting, sex while using methamphetamine and using inhaled drugs.

Comment: Because we can treat hepatitis C so effectively now but treatment is costly, it’s important to try and provide really effective advice and develop useful risk-management strategies for the subset of gay men who are at particular risk of hepatitis C. In the two European PrEP studies, where HIV incidence in men not receiving PrEP was 9% and nearly 7% respectively, hepatitis C incidence was 3.1% (in those tested for hepatitis C) and 2% respectively, showing that not only men already with HIV, but also a high proportion of men who seek PrEP, may benefit from regular hepatitis C screening and harm reduction advice. The researchers comment that testing for hepatitis C only when symptoms such as raised liver enzymes suggested it was not adequate for the new era of treatment.

Studies find that viral undetectability is becoming part of people’s sex lives

Several recent studies have found that gay men and sero-different couples are increasingly familiar with the effect of HIV treatment on infectiousness; are starting to regard the achievement of an undetectable viral load as a significant milestone; and that this is having positive effects on relationships that were previously experienced as full of risk.

A Canadian study in gay men living with HIV found that they incorporated knowledge of their own undetectable status into their identities and their sexual decision making. Having an undetectable viral load helped many men feel ‘responsible’ and ‘normal’.

Similarly, an Australian study found that understanding the impact of HIV treatment on prevention is changing the experience of being in a relationship with a partner of a different HIV status. Viral undetectability appears to be loosening the association of sero-different relationships (in which one partner has HIV and the other does not) with ‘risk’ and helping couples to experience their relationships as normal and safe.

Finally, almost half of American gay men (43% of HIV-negative and 62% of HIV-positive) surveyed via a major dating app said that at least one potential sexual partner has said that he was taking pre-exposure prophylaxis (PrEP), and even more (68% of HIV-negative and 90% of HIV-positive) have interacted with someone who said that he was HIV positive but had an undetectable viral load. The researchers coined the phrase ‘biomed matching’ for sero-different men who decided to have condomless sex where one had an undetectable viral load and the other was on PrEP – or for HIV-negative sexual partners where both men were on PrEP.

Comment: It has taken a long time for the knowledge about undetectable viral load and infectiousness, in particular, to filter through to people with HIV and their partners. The Australian researcher commented that when she previously researched the topic in 2009, soon after the ‘Swiss statement’ was issued,  people in a relationship with a partner of a different HIV status often expressed scepticism or uncertainty about the idea that HIV treatment could make a person non-infectious. In her more recent interviews, conducted in 2013 and 2014, couples readily discussed the implications of having an undetectable viral load.

A third of people with HIV intentionally miss HIV treatment doses when planning to drink or use drugs

False beliefs about possible toxic interactions between antiretroviral therapy (ART) and recreational drugs and alcohol are causing large numbers of people living with HIV to intentionally miss doses of their HIV treatment. The study of 530 people in Atlanta, USA, found that 35% reported missing treatment doses because of beliefs about potential interactions with drugs and alcohol.

This planned non-adherence was associated with sub-optimal compliance to treatment and poor control of viral load. Participants with intentional non-adherence took 79% of their ART doses. This compared with 85% for other participants. A third of participants who purposefully missed ART doses had a detectable viral load compared to 22% of participants who did not report intentional non-adherence.

Participants stopped their HIV treatment because they believed that recreational drugs or alcohol would stop their HIV drugs working or would lead to side-effects, or that HIV drugs could lead to overdoses. While some HIV drugs do interact with some recreational drugs, in the main the study participants’ concerns were misplaced.

Comment: This is an interesting study because its findings were unexpected: we had no idea that a lot of people who take recreational drugs assumed it was always unsafe to combine them with one’s HIV therapy. This may not only be due to misunderstandings about the relatively few interactions one does have to be careful about – notably with the booster drugs ritonavir and cobicistat – but also due to inaccurate or over-cautious information given out by healthcare workers.

Other recent news headlines

PROUD PrEP study results published

The results of the PROUD study of HIV pre-exposure prophylaxis (PrEP) using daily tenofovir + emtricitabine (Truvada) have now been published in The Lancet scientific journal. PROUD, along with the other European randomised study of PrEP, Ipergay, demonstrated considerably higher levels of effectiveness of PrEP in preventing HIV infections than any previous study. There is little difference between the results in The Lancet and those presented at a conference in February, but journal publication is important for the provision of PrEP in Europe. The European Medicines Agency (EMA), which regulates the licensing of medicines, and the European Centre for Disease Prevention and Control (ECDC), which issues public health recommendations, both require journal publication for studies to be included in their evidence.

Gay men in Uganda talk about why they do not always use condoms

Gay men and other men who have sex with men in Uganda, who had not used a condom the last time they had anal sex with another man, were most likely to report condoms not being strong enough for anal sex, a lack of suitable lubricant and, in rural areas, a lack of access to condoms as the most common reasons they did not use them.

Major barriers need to be addressed for PrEP to have an impact, US analysis says

The uptake of PrEP in people who need it risks being limited due to low levels of awareness, gaps in health insurance, opaque bureaucratic procedures, under-usage of medical services, and limited awareness and skills in healthcare providers, a US study has reported. The researchers conclude that just 15% of gay men in Atlanta who could benefit are likely to achieve protection from HIV with PrEP. The biggest single barrier to effective PrEP use was lack of awareness.

Testing campaign in Thailand suggests how local cultures can influence testing behaviour

A campaign to encourage Thai gay men and other men who have sex with men to test at least once a year for HIV has had modest success, with repeat testing rates increasing slightly over the study period. However, rates of re-testing are, at about 25% within a year, still far below the 90% recommended by the Thai Ministry of Public Health (MOPH). One of the most intriguing aspects of this study is that testing was far more likely around men’s birthdays and during festival periods. While there has been no qualitative work to ask why, researchers suggested that Thai Buddhist ideas about performing 'good deeds' on birthdays could be capitalised on to increase testing rates.

How methadone is promoting ART adherence for drug users in Ukraine

from International HIV/AIDS Alliance

Globally, it is estimated that 1.65 million people who inject drugs are living with HIV. Yet access to antiretroviral treatment remains a major problem. At the 24th International Harm Reduction Conference coming up in Malaysia in October, innovative ways in which harm reduction programmes are being shaped to help drug users access the antiretroviral treatment they need will be presented.

Activists shout out for PrEP in Melbourne

from Same Same

Frustrated HIV prevention activists have targeted the streets of Melbourne, Australia, with an abrupt and controversial grassroots campaign designed to urgently reactivate conversation about PrEP. “YOU CAN F**K RAW,” say the posters, seen in Melbourne’s Central Business District. “PrEP WORKS – NO MORE HIV.”

STI trends in Europe: chlamydia rates stabilise while gonorrhoea numbers go up

from ECDC

With an estimated 146 million infections each year, chlamydia is the most common sexually transmitted infection worldwide. And Europe is no exception, with almost 385,000 cases reported in 2013 alone and more than 3 million between 2004 and 2013. But while trends in the number of chlamydia infections appear to have stabilised in recent years, gonorrhoea rates have gone up by 79% since 2008, particularly among men.

Russia's HIV patients struggle to get treatment

 from The Moscow Times

When Russian health care officials announced they would start replacing foreign HIV medication with drugs produced in Russia, patients' rights advocates were quick to point out that HIV patients have complained that domestic drugs are ineffective and have undesirable side-effects – but patients themselves say that drug shortages are a far bigger problem for them.

Europe’s response to HIV: ECDC reports identify key areas for action

from ECDC

In a set of reports, ECDC gives an overview of how European countries have been responding to the HIV epidemic since 2004 based on the commitments as outlined in the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia.