You may have an undetectable viral load, but your partner may still need PrEP or PEP
New HIV infections among the HIV-negative gay men in the PARTNER study, due to sex with partners outside the main relationship, was high, a recent conference heard.
PARTNER made headlines by demonstrating that there were no transmissions from an HIV-positive partner who was on antiretroviral therapy and virally suppressed in almost 60,000 acts of condomless sex. These data allowed the researchers to establish the maximum possible likelihood of transmission, and to announce that, most likely, the chance of an HIV-positive partner with a fully suppressed viral load of below 200 copies/ml passing on HIV was zero. PARTNER provides crucial evidence for the U=U (Undetectable = Untransmittable) campaign.
However, there were HIV infections in PARTNER: eleven of them by 2016, ten in gay men. In all cases, however, phylogenetic testing showed that the infecting virus came from someone other than the primary partner.
Each year, 2% of HIV-negative gay male partners acquired HIV. Looking only at those men who reported having condomless anal sex with non-primary partners, each year 7% acquired HIV.
In short, men whose main partner is undetectable are not safe from HIV if they are also having condomless sex with other people. In this situation, it would make sense for the HIV-negative man to use post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP).
But very few of those taking part in the PARTNER study did so, resulting in these high levels of infection.
HPV and anal cancer
HPV (human papillomavirus) is a sexually transmitted virus that causes genital warts, and in some forms, leads to the development of cervical, anal, mouth and throat cancers. Anal cancer, rare in the general population, is becoming more common in people living with HIV, especially men who have sex with men.
The European AIDS Clinical Society has strengthened its advice on vaccination against HPV. All people living with HIV under the age of 26 and all gay men living with HIV under the age of 40 should be vaccinated, it says. These recommendations are in line with the guidance of the British HIV Association (BHIVA).
The reason why these guidelines include upper age limits is that the older you are, the more likely it is that you have already been exposed to several types of HPV, making the vaccine less effective. The younger you are, the more likely you are to benefit from vaccination.
Recently, Dutch clinicians reported on their experience of screening gay men living with HIV for pre-cancerous anal lesions. This is not the same as anal cancer, but having these pre-cancerous cell changes is associated with a small risk of developing cancer in the future. The lesions might go away on their own, but in case they don’t, many doctors would recommend treatment.
Of just under 1700 men who were screened, they found that 30% had high-grade lesions. Given this high rate, the clinicians believe that screening all gay men living with HIV would be a good idea.
Nonetheless, screening for pre-cancerous anal cell changes in people who don’t have symptoms is not currently recommended in guidelines. This is because we don’t yet know whether the available treatments are good enough to make screening worthwhile in people who haven’t got symptoms. The treatments can be uncomfortable, have side-effects and don’t always stop high-grade lesions from recurring. It could be worrying to find out that you have pre-cancerous lesions, but if you didn’t know you had them, it’s possible that they would go away on their own or cause you no harm.
On the other hand, some experts believe that finding and treating high-grade lesions promptly will prevent cases of anal cancer that would be much harder to treat later on, so they think it is worth getting tested regularly.
These doctors also point to high rates of anal cancer in gay men living with HIV, for example a recent analysis from Austria – in men under 50 years, 8 in 1000 had ever had anal cancer; in men over 50 years, 26 in 1000 had ever had it. As the risk of cancer increases the older we get and more people with HIV are going to live longer in future years, these rates could increase further as time goes on.
For more information, read NAM’s factsheet ‘Anal cancer and HIV’.
Does U=U apply to breastfeeding?
Taking effective HIV treatment and having an undetectable viral load massively reduces the risk of onward transmission during breastfeeding, but it does not appear that the risk is zero, a leading paediatrician from St Mary's Hospital, London said last week. Dr Hermione Lyall said that she often needed to advise women who were doing well on HIV treatment, with an undetectable viral load, who wished to breastfeed.
Studies from African countries suggest that for women with HIV taking treatment (not necessarily undetectable), around 1 to 2 in 100 may pass on HIV to their baby. More reassuringly, a recent Tanzanian study found that among 177 mothers, there were no transmissions from mothers with undetectable viral loads. This suggests that there is a very low risk of breastfeeding transmission when viral load is suppressed, but these are not enough data to say that the statement “undetectable = untransmittable” (U=U) applies to breastfeeding as well as to sexual transmission.
Dr Lyall says that women with HIV should be advised that formula feeding has a zero risk of HIV transmission and is the safest thing to do. Nonetheless, some women will choose to breastfeed and healthcare professionals should support them to do so as safely as possible.
Mothers should be advised that having an undetectable viral load, taking all their doses of their treatment and limiting the duration of breastfeeding will help lower the risk of passing HIV on. They should attend monthly check-ups with their clinical teams.
Dr Lyall also presented three key safety points that women should remember while they breastfeed:
- No virus: Only breastfeed if your HIV is undetectable.
- Happy tums: Only breastfeed if both you and your baby are free from tummy problems.
- Healthy breasts for mums: Only breastfeed if your breasts and nipples are healthy with no signs of injury or infection.
For more information, read 'After your baby is born' in NAM’s booklet ‘HIV & women’.
Healthcare workers living with HIV
Nurses and other healthcare workers who are living with HIV have mixed reactions when they mention their HIV status to colleagues, according to a small Dutch study. Some healthcare workers disclosed because they were confident they would have a positive reaction or because concealment was stressful. Very often, those disclosed to saw the participant’s HIV status as a non-issue, as one interviewee explained:
“In the beginning, it was talked about and thought about a lot but that was, at a given moment, gone and nobody gave it anymore thought.”
Other interviewees concealed because they did not believe that disclosure was relevant or necessary. Some people did not discuss their HIV status because they expected negative reactions or stigma, often because they had previously experienced this themselves or had seen it occur in relation to other people.
“I’m not going to tell them anymore because I’m, yeah, I’m scared of how my colleagues will react. And where does this come from? It comes from, for example, the fact that whenever a patient is admitted and he has HIV, then they immediately say, ‘You need to be careful, eh? He has HIV so be extra careful’.”
The researchers say that it’s important to emphasise that disclosure is a choice. Before disclosing at work, people should think carefully about their motivations for disclosure and the potential reactions they might have. The authors comment that while disclosure can be a good idea if it results in social support or less stress, it may sometimes be better to conceal at work, especially when the risks are great and social support is available elsewhere.
For more information, read 'Deciding whether to tell people that you have HIV' in NAM’s booklet ‘HIV, stigma & discrimination’.
Heart disease and kidney disease
People who were assessed as being at high risk of cardiovascular disease were also more likely to go on to have kidney disease. Similarly, being at high risk of kidney disease increased people’s risk of having cardiovascular disease. Rates of subsequent disease were especially high in people who had been assessed as being at risk of both.
The researchers say that doctors should assess the risk of these conditions together. They should also focus on encouraging people with HIV to make lifestyle changes which lower the risk of both conditions – eat a healthy, balanced diet; exercise regularly; lose weight if you're overweight; don’t smoke; and limit your intake of drugs and alcohol.
Editors' picks from other sources
from Bristol Post
People living with HIV say Avon and Somerset police are “disgusting” for suggesting the immunodeficiency virus can be contracted through spitting. One HIV-positive man, who has asked not to be named, claims the language used around the police’s announcement that its officers would be allowed to put ‘spit hoods’ over the heads of people who have been arrested only furthered “misconceptions and lies” about HIV.
A British LGBTQ advocacy group is hoping to clarify some misconceptions about what it means to be HIV undetectable in a quirky new video. The Undetectables, released earlier this month, features testimony from 12 gay men who are living with HIV.
This is what it's like to be one of the men infected by HIV in Britain's first case of deliberate transmission
Despite the nature of Daryll Rowe’s crimes, and the multiple tabloid headlines surrounding this case screaming about an already highly stigmatised condition, this is not really a story about HIV. The virus was merely Rowe’s weapon of choice. This is a story about abuse.
The royal visited the Terrence Higgins Trust (THT) HIV testing center in Hackney, north London, on Wednesday last week to launch this year's National HIV Testing Week. During his visit he watched a live demonstration and met some the shop's volunteers.
from The King's Fund
The drop in new diagnoses among gay and bisexual men must be seen as an indicator of the reductions that are possible, rather than meaning that the job is done or that a downwards trajectory in new diagnoses will continue in the future. Importantly, so far these reductions have only been seen in one population group.
from Alex Sparrowhawk (blog)
Misuse of the term 'stigma' continues to control the behaviours of people living with HIV. It is all too common to blame this monster in the dark, a beast lurking on the streets than it is to blame our own family and friends, the people we love for their fear or ignorance. And we also need to stop telling people living with HIV that they will be stigmatised.