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UK statement: treatment "as effective as condoms" in reducing HIV transmission
The UK’s Expert
Advisory Group on AIDS (EAGA) and the British HIV Association (BHIVA) has
published a position statement on the use of HIV treatment to reduce the risk
of transmission. For the first time, the
document provides UK
health professionals with a consensus statement that can be used to guide
discussions with individuals.
Noting that in the HPTN 052 study, the HIV-positive partner in a positive/negative (serodiscordant) couple
was 96% less likely to transmit HIV if they were on antiretroviral therapy
(ART), they say: “The observed reduction in HIV transmission in [this] clinical
trial demonstrates that successful ART use by the person who is HIV positive is
as effective as consistent condom use in limiting viral transmission”.
There has never been a randomised controlled trial of
the efficacy of condom use. However, meta-analyses
of observational studies of serodiscordant
couples who reported 100% condom use have found the strategy to be about 80%
effective in reducing HIV infection.
The statement adds that, unlike ART, condoms can
prevent other sexually transmitted infections.
The document states that the risk of transmitting HIV
during vaginal intercourse is “extremely low”, provided that the person with
HIV is on ART and has had a sustained viral load below 50 copies/ml for more
than six months, that there are no sexually transmitted infections in either
partner and that viral load testing occurs every three to four months.
The statement notes that data are not available for
anal intercourse or for transmission via needles but says: “It is expert
opinion that an extremely low risk of transmission can also be anticipated for
these practices, provided the same conditions stated above are met”.
that healthcare professionals should discuss the impact of ART on sexual
transmission with all people living with HIV. For people not currently on
therapy, the possibility of starting treatment in order to reduce transmission
risk should be discussed.
Comment: The current BHIVA
treatment guidelines already recommend that HIV doctors discuss the
effectiveness of ART as HIV prevention with all their patients. The importance
of this statement is that it is co-written with EAGA, which was set up in 1985
“To provide advice on such matters relating to HIV/AIDS as may be referred to
it by the Chief Medical Officers of the Health Departments of the United
Kingdom”. EAGA consists of HIV physicians, other medical experts, and lay members
and the authors of the statement include representatives from BHIVA, NAT,
MEDFASH, NAM and the Department of Health. This advisory document aims to help
doctors and patients talk about the use of ART as prevention, but also to
provide evidence to make the case for the provision of resources to support its
Condoms used in a quarter of heterosexual encounters in the US
heterosexual adults in the United States used a condom the last time they had
vaginal sex, researchers from Indiana University have found. Most people reported that condom use made no difference to sexual
pleasure, to orgasm, or, in men, to maintaining an erection.
However, men reported a small but statistically
significant reduction in sexual pleasure when they used condoms without also
using an extra lubricant, and women reported more difficulty in achieving
Neither condom nor lubricant use affected whether
partners had an orgasm, or whether they perceived that their partner did. There
were interesting gender differences, though: while 95% of men had an orgasm and
94% of women perceived that they did, only 66% of women had an orgasm –
although men thought they did 90% of the time.
Condoms were used by 27.5% of men and 22% of women the
last time they had sex. Of those who did not use a condom, 25% of men
(18% of all men) and 29% of women (22.5% of all women) used a sexual lubricant,
while only 5% of men and women reported using both a condom and extra
This left 61% of men and women who used neither condom
Eighty per cent of lubricants used were water- or
silicone-based. Only four men and two women reported using oil-based products with condoms, but in all cases these
were latex condoms, which would be weakened by the lubricant.
Comment: This was not a study of
couples, but individual men and women. As a result condom use cannot be related
to what kind of partner participants were having sex with, although condom use
approximately matches the proportion of casual/new partners. While 25% of
heterosexual people used condoms last time they had vaginal sex, in the
matching gay men’s survey, 45% of gay men reported using a condom last time they had
anal sex. It is
encouraging to note that, in this survey at least, condoms were reported as
only very slightly affecting sexual pleasure and that using oil-based
lubricants with them was rare.
HIV infections in gay men unchanged or increasing in England and Wales, despite more testing
The number of
gay men in England and Wales who become infected with HIV each year has
remained unchanged between 2001 and 2010, according to a paper by the UK
Medical Research Council and the Health Protection Agency (HPA). This is despite a considerable increase in testing and, they estimate,
a 40% reduction in the proportion of gay men with HIV who are unaware of their
The number of HIV diagnoses in gay men increased from
about 1800 in 2001 to 2600 in 2010. Some of this increase is due to increased
testing, however, and by adjusting this for the likely length of infection, as
estimated by CD4 count at diagnosis, the researchers estimated that the true
annual total of HIV infections in gay men has scarcely increased, from 2200 in
2001 to about 2300 in 2010.
The number of HIV tests taken by gay men in sexual
health clinics has grown nearly fourfold, from 16,000 in 2001 to 59,300 in
2010. As a result, the estimated time between infection and diagnosis has
shrunk from four years to 3.2 years during this time, and the proportion of gay
men with HIV who are undiagnosed from 37 to 22%.
The reason it has not shrunk more, say the authors, is
due to gay men not testing often enough. Last year, the HPA reported that only an estimated 10 to 15% of gay men took an HIV test every
year, and that two-thirds of gay men who tested at a clinic had, two years
later, not returned to that clinic for another test.
The total number of gay men with HIV who are
undiagnosed in England and Wales
was estimated as 7690 in 2010.
second paper published
shortly afterwards and including some of the same authors tested the
assumptions used to estimate HIV incidence in the first paper. They concluded
that, based on the observed number of diagnoses, HIV incidence in gay men may
in fact have risen from 0.3% a year in the 1990s to 0.53% in the last five
Comment: The UK has a high proportion of people diagnosed with HIV in
care, on ART, and undetectable, and very low patient dropout rates. As a result
53% of all people with HIV (including the undiagnosed) are on ART with an
undetectable viral load, as opposed to 28% in the US. But 22% of gay men with
HIV remain undiagnosed in the UK as opposed to 14% in Vancouver and only 6% in
San Francisco – and maybe half HIV infections in gay men come from the
undiagnosed and recently infected. Increases in testing in gay men are not yet
bringing down new infections and it is clearly time for a campaign to get gay
men, especially, to test more regularly.
No HIV infections from partners on treatment in Ugandan couples
study of heterosexual couples in Uganda has found more evidence that
antiretroviral therapy (ART) can curb HIV infection within the community. The study found 119 new HIV infections in 2334 couples over the course
of the study, and 62 infections among the 254 couples that initially or at some
point had differing HIV status. But it did not find a single example of
transmission from a partner who was on antiretroviral therapy.
The study, conducted between 1989 and 2007, also found
that the rate of HIV infection between couples declined during this time and
that transmission likelihood was related to the HIV-positive partner’s viral
In 2011, the HPTN 052 study found that the HIV-positive partner in a positive/negative couple was
at least 20 times less likely to transmit HIV if they were on ART than if
untreated. This result, however, was achieved within the highly controlled
environment of a randomised scientific trial, and we need more data on whether
ART is significantly reducing the risk of transmission in ‘real world’ settings.
Compared to people with viral loads under 10,000
copies/ml, people with viral loads between 10,000 and 50,000 copies/ml were
over twice as likely to transmit HIV and people with viral loads over 50,000
copies/ml nearly six times as likely. However, because viral load results were
only available for a minority of participants, this effect also did not reach
During the study period, some of the HIV-positive
partners started ART. None of them transmitted HIV, compared with 62
transmissions from HIV-positive people not on ART (transmission rate 7.35% a
year). This difference was highly significant.
Comment: The important point about
this study is that it was conducted in the community, not in a highly monitored
setting. It adds to the weight of evidence that ART is reducing HIV
transmissions, but we’ll need several more years of data for the findings to
become really convincing. One point worth noting is that in this study 44% of
new infections did not occur between the serodiscordant couples. In HPTN 052,
which DNA-tested everyone’s HIV, 28% of infections ‘in couples’ were in fact
acquired from someone else, and a recent study in the Lancet estimated that, in stable
couples in Africa, 30% of all new HIV infections in men and 10% in women were
due to sex outside the relationship.
Circumcision makes no difference to HIV infection in UK gay men
A survey of
white, British-born gay and bisexual men in the UK found no association between
whether they were circumcised and whether they had HIV, even among men who were
exclusive ‘tops’ (took the insertive role in anal intercourse).
There has been an ongoing debate about whether
circumcision might protect gay men who take the top role in anal sex. A couple of
studies have reported that it is protective but more have not.
Over 17,000 men responded to the MESH survey and, of nearly 5000 who said they had unprotected sex and disclosed
their HIV status, 1521 (31%) reported that they mainly (20%) or exclusively
(11%) took the insertive role. Of these men, one in six was circumcised.
Of these 1521 men, 1097 had taken an HIV test.
Ninety-seven men (8.8%) reported that they had HIV and there was no difference
in HIV prevalence between circumcised (8.6%) and uncircumcised (8.9%) men.
Being exclusively, as opposed to mainly, top was
highly protective against HIV, as other studies have found: 5% of exclusively
insertive men were HIV positive as opposed to 11% mainly insertive men – a 58%
reduction in HIV risk. A previous
study has shown that being an exclusive top confers an 89%
reduced rate of HIV versus all other sex roles.
Even in exclusively insertive men, though, there was
no difference in HIV status between circumcised (5.3%) and uncircumcised (4.9%)
men. Taking other factors into account, circumcised men who were exclusive tops
were 16% less likely to have HIV but this is likely to be a chance finding and there
is certainly nothing approaching the 60 to 70% reductions in HIV risk seen in
randomised controlled trials of circumcision as HIV prevention for heterosexual
men in Africa.
Comment: This study, with a
reasonably large sample, strongly suggests that circumcision would not be an
effective HIV prevention strategy for gay men in general, regardless of their
preferred sex role. It does beg the question of why circumcision did not
protect gay men who always took the insertive role. It’s unlikely to be because
participants did not tell the truth about their sex role because the
proportions reporting being top, bottom and versatile were the same as those
seen in other surveys. Circumcision may not be protective in anal sex, or what
gay men do now may not be a good guide to what they were doing at the time they
European HIV prevention webinars – microbicides
part of its European HIV prevention work, NAM is collaborating with AVAC to provide
a series of webinars (conference calls with accompanying slides) to train and
inform prevention advocates and anyone interested in the newest developments in
HIV prevention technology.
second webinar is entitled:
Microbicides research in Europe and beyond
90-minute webinar will examine the current state of research into topical microbicides
– gels, lubes and devices that can be used to prevent HIV transmission during
sex. It will provide advocates with an overview of global and European topical
microbicide research. The presentations will be followed by a question and
answer session with our expert speakers. The webinar will be conducted in
and date: 2pm UK time (GMT), Tuesday 26 February (3pm CET)
To register for the webinar and get phone numbers and joining
instructions click this link: https://cc.readytalk.com/cc/s/registrations/new?cid=nhmm1k9bdrm6
webinar will feature presentations by:
McCormack – Overview of topical microbicide research
Sheena McCormack is Senior Clinical Scientist at the Clinical Trials Unit of
the UK Medical Research Council. She is Principal Investigator of the Microbicides
Development Programme, which ran the MDP
301 Phase III microbicide trial in four countries in
sub-Saharan Africa, and of the recently started PROUD trial of Truvada pre-exposure prophylaxis in UK
Dr Charles Kelly – outstanding research from the CHAARM microbicides
Charles Kelly of King’s College, London is co-ordinator of the Combined Highly
Active Anti-Retroviral Microbicides (CHAARM) programme, a collaborative project
co-funded by the European Union under the 7th Framework Programme (FP7) for
Research and Technological Development. CHAARM is a consortium of 31 partners
representing 9 different countries in Europe including Ukraine, as well as
South Africa and the US, with a €12m budget.
Jeremy Nuttall – Update on IPM’s
pipeline: the dapivirine ring and beyond
Nuttall is the Senior Director of Preclinical Sciences and Product Development
for the International Partnership for Microbicides (IPM), where he is
responsible for the preclinical testing of candidate microbicides and has
broader product development responsibilities. Jeremy joined IPM in 2003
and has over 25 years of experience in drug development. Prior to IPM he
worked as a toxicologist in contract research organisations and spent over 8
years in regulatory affairs at GlaxoSmithKline.
Harriet Langanke – Community
advocacy for microbicides in Europe
Langanke is founder and director of GSSG: Gemeinnützige Stiftung Sexualität und
Gesundheit, the German Foundation Sexuality and Health. She is a journalist
working in the field of HIV and sexual health since 1991; she is also one of
the co-founders of Germany’s national network women and AIDS which celebrated
its 20th anniversary last year. As an expert for HIV and STI
prevention she works primarily for and with women.
discussion will be introduced and moderated by Gus Cairns. Gus is a writer at NAM, where he
edits HIV treatment update and Preventing HIV. He also
edits this HIV prevention news: Europe bulletin
as part of NAM’s programme of European prevention advocacy. He is a member of
the European AIDS Treatment Group, co-chair of the Steering Committee of the
PROUD PrEP trial, and a member of the steering committee of the Global Forum
for MSM and HIV.
advocates interested in learning more about microbicides, and the role that
Europe is playing in microbicide research, are encouraged to join this webinar
and to email questions in advance to email@example.com. During
the event, participants will be encouraged to ask questions via telephone.
To register for the webinar and get phone numbers and joining
instructions click this link: https://cc.readytalk.com/cc/s/registrations/new?cid=nhmm1k9bdrm6
The following webinar, scheduled for 26 March, will examine
the latest data on HIV treatment as prevention.
Other recent news headlines
US researchers have found that the average HIV viral
load in people not taking HIV treatment in Africa is two to five times higher
than the viral loads of untreated patients in the US and Europe. The
researchers estimated that if viral loads in Africa had been the same as those
in the US, there would have been 14% fewer infections in general and 25% fewer
in low-risk heterosexuals. They attribute the higher viral loads to a higher
proportion of untreated sexually transmitted infections.
A campaign that aimed to raise awareness among gay men in
Seattle, Washington, of the symptoms of acute HIV infection was only recalled
by a quarter of the target audience and had no impact on gay men’s knowledge or
testing behaviour. The ‘ru2hot?’ campaign listed the symptoms of acute infection (especially fever) and encouraged men with symptoms to get tested. But there were only 1164 unique visitors to the site during a two-year period for a spend of $19,038 over three years. The efficacy of media
campaigns to alert people to HIV is rarely measured and this study, the
researchers comment, warns that it should be evaluated more often.
US researchers have found a high incidence of
hepatitis C (HCV) infection among gay men with HIV. Annual incidence at the
Fenway HIV clinic in Boston was 1.6% – about one new HCV infection a year in 60
men. In the study, 1059 out of 1160 clinic attendees was tested for HCV and 6%
were found to have it. But only 379 had a repeat test over the next few years,
and among them, another 6% tested positive. The authors conclude that
HIV-positive gay men should be tested annually for hepatitis C.
The medical journal The Lancet has published a news feature describing increasing use of methamphetamine among London gay men and
an increasing number who inject it. Data from Antidote, a drug and alcohol project working with lesbian, gay, bisexual and
transgender people in London shows that in 2006, just 5 of its 249 service
users (2%) presented with methamphetamine use as their main problem while in
2010, 187 of 553 service users (34%) had meth as their main problem, with a
further 78 people (14%) reporting its use in addition to another substance they
had difficulties with.
Editors' picks from other sources
New US HIV treatment guidelines recommend that
everyone diagnosed with HIV should be treated with antiretrovirals (ARVs),
although they acknowledge that evidence for the benefit of treatment in people
with CD4 counts over 500 is based on non-unanimous expert opinion. They also
say that antiretroviral therapy (ART) is generally recommended for people with
HIV for the prevention of transmission of HIV, and say that although this is
also expert opinion when it comes to anything other than vaginal sex and
mother-to-child transmission, it is a “strong” expert opinion, implying
consensus. The guidelines add: “Patients starting ART should be willing and
able to commit to treatment and understand the benefits and risks of therapy
and the importance of adherence.”
from International Rectal Microbicide Advocates (IRMA)
International Rectal Microbicide Advocates (IRMA) has
issued a call to action demanding that the international research community
investigates the safety of sexual lubricants. Studies
have shown that commonly used lubricants damage the lining of
the rectum and vagina, but no systematic research has been done to find out if
this increases the risk of HIV infection.
from The Guardian
In the past few years, psychologists and doctors have
discovered that policy changes for or against same-sex marriage can influence
patterns of health care for lesbian and gay people. One study followed
the mental health of lesbian, gay and bisexual (LGB) individuals living in
states who voted for constitutional amendments to ban gay marriage and found
that people living in states that enacted the amendments showed higher rates of