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People start treatment no earlier than they did 20 years ago
average CD4 cell count of people newly entering HIV care in resource-rich
countries did not increase meaningfully between 1992 and 2011, US and UK
researchers have found.
accompanying editorial, former International AIDS Society President Professor
Joep Lange commented that it was “astonishing” that “so little has changed with
regard to time of presentation to HIV care in a period that saw dramatic
improvements in HIV treatment and monitoring. Many people with HIV infection in
high income-countries [still] present late for care and may start treatment
researchers conducted a systematic review of studies reporting on CD4 cell
count at the time of entry to care between 1992 and 2011. During this period
there were major advances in HIV diagnostics, monitoring, care and treatment.
They identified 44 studies covering 169,000 patients, two-thirds from the US or
mean CD4 cell count of people entering care in 1992 was 307 cells/mm3 and
in 2011 it was 336 cells/mm3 – an increase of only 1.5 cells/mm3
a year. Over the same period, there was only a 2% reduction in the proportion
of people presenting late, i.e. with CD4 counts below 350 cells/mm3.
authors believe their findings have significance for debates about the use of
antiretroviral treatment as prevention: “The promise of such approaches is
unlikely to be realized unless improvements in timeliness of HIV diagnosis and
presentation for care are achieved, dramatically altering the trajectory of the
temporal trends observed over the past 2 decades,” they say.
Considerable increase found in unprotected sex in French gay survey
French and French-Canadian online survey of gay men and other men who have sex
with men (MSM) appears to have uncovered a dramatic increase in the rate of
unprotected sex with casual partners, potentially serodiscordant sex, and
sexually transmitted infections.
fourth Gay Net Barometer, a behavioural survey of gay men and MSM using gay
dating websites and social networks, found that, while in the previous survey
in 2009 43% of participants reported having had at least one experience of
unprotected anal sex with a casual partner, in 2013 it is 55% (so far: the
survey is still online until 30 September). Furthermore, the proportion
reporting regular unprotected sex
with casual partners has risen from 26 to 37%.
2009, only 15% reported having unprotected sex with partners of different or
unknown HIV status: in 2013, the figure was almost twice this at 28.5%.
increases in risk behaviour appeared to be having health consequences, too. In
2009, 9% of participants reported being diagnosed with a sexually transmitted
infection (STI) in the past year. In 2013 the proportion was nearly twice this,
was a significant difference in HIV status according to how participants
accessed the survey. While the mean HIV prevalence in participants was 13%, in
participants accessing the site via general social-networking sites (rather
than gay-specific ones) was only 4.4%. The researchers interpret this as a
difference in the age of those reporting: young people are both less likely to
have HIV, and less likely to have taken a test and know their status.
gay-specific sites seems to be something mainly done by older gay men, and
their membership may be “stagnating”, the researchers say: the average age of
men responding from the general social-network sites was 32, but on
gay-specific sites was 39.
surveys appear to show a slight increase in the proportion of participants who
regard themselves as bisexual, from 16% in 2009 to 20% in 2013.
The current survey is the fourth in the
series and is still collecting responses: the survey page is here and it can be answered in French or
study’s findings on sexual risk are striking enough in themselves. What they
also found was that younger gay men, in particular, had a sense of
disengagement from the gay community and no longer saw their sexual risk
behaviour as being sustained by specific community norms. See also the
‘bareback’ story below for more on this.
European women with HIV still having unnecessary caesareans
are “missed opportunities” for HIV-positive pregnant women with a suppressed
viral load to give birth vaginally, European research shows.
in Europe recommend or permit a vaginal delivery when a woman has an
undetectable or very low viral load. However, investigators found that over a
third of women with viral suppression and no other contraindications for a
vaginal delivery continue to have a caesarean section.
of vaginal deliveries were lower than expected,” comment the authors. “Our
results suggest that the policy for vaginal delivery among women with
undetectable or very low VL [viral load] is only slowly becoming established
within practice over time.”
elective caesarean section was recommended for HIV-positive women in 1999, but
the widespread use of antiretroviral therapy (ART) has reduced the risk of
mother-to-child transmission dramatically, with rates of below 1% seen across
Europe. Guidelines have been changed over the last decade to recommend that
women with very low viral loads aim for a vaginal birth. The additional
benefits of an elective caesarean section are open to question, especially as
the procedure can also involve risks.
collected between 2000 and 2010 from 3013 deliveries to 2663 women were
available for analysis.
8% of mothers did not receive ART during pregnancy or delivery and the
proportion of women taking ART who achieved a viral load below 400 copies/ml at
the time of delivery increased from 83 to 95% (87% of all the women) after the
new guidelines were in place.
after the change in guidelines, the proportion of women giving birth vaginally only
increased from 17 to 52% and the proportion of vaginal deliveries in women with
viral loads under 50 copies/ml was actually lower, at 45%. For a third of the
remaining women, there was another reason for having a caesarean, but in 35% of
cases the woman could have aimed for a vaginal delivery.
study suggests, as do many others, that people with HIV, and particularly groups
traditionally less empowered such as women, are still being affected by
out-of-date knowledge and attitudes among healthcare workers.
'Bareback' sex has the lure of the forbidden for gay men
qualitative surveys presented at the 2nd
International Conference for the Social Sciences and Humanities in HIV
in Paris last month explored how gay men interpret the term ‘bareback sex’ –
and found sharply polarised attitudes to it among the gay community.
Gabriel Girard interviewed 30 gay men in France, where ‘bareback’ has been the subject
of intense and divisive debate.
of his participants felt part of the ‘gay community’, believed that barebackers
threatened it, and that they should be excluded from it – one man said that men
who bareback “are doomed”. Deliberately not using condoms suggested a
lack of respect for gay men who had died of AIDS in the early years of the
respondents had a more analytic view of barebacking, and could find
explanations in terms of psychology, contextual factors or the history of the epidemic
(e.g. the arrival of effective HIV treatments). Moreover, many of these
respondents were critical of the way in which different sexual practices, with
divergent motivations, were sometimes all publicly described as ‘barebacking’.
While some of these respondents did practise unprotected anal intercourse with
casual partners, none would call themselves a ‘barebacker’.
said that debates about barebacking need to go beyond an opposition between individualism
and the community,
another study, UK researcher Sharif Mowlabocus asked gay men about their
feelings about pornography in which condoms were not used and whether they
defined it as ‘bareback’.
‘bareback porn’ is most obviously pornography in which condoms are not used,
the research found that not all scenes without condoms were labelled as
the researchers described a scene involving two ‘twinks’ (boyish-looking,
younger men), having unprotected anal intercourse, the focus group participants
consistently refused to acknowledge it as ‘bareback’. Sometimes they ignored
the lack of condoms or explained it away.
which were seen as ‘bareback’ tended to be transgressive in some way, often
involving an age difference, anonymity, different ethnicities or emphasising
power and control.
of the interviewees said that they enjoyed bareback porn and that it was often”hotter”.
As well as appearing to be more “authentic”, several interviewees said that the
“hotness” of bareback porn often lay in the fact that it was representing
something that was taboo.
discovered there were people against it, arguing it was degrading and
dangerous. This fiendish side of it attracted me, and I started buying some,” said one respondent.
Mowlabocus said that a paradoxical process was
happening for gay men whereby “the constraints that HIV imposed upon gay
culture have become eroticised”.
Comment: These studies show that, by demonising
unprotected sex as ‘bareback’, HIV prevention advocates may have inadvertently eroticised
it. Barebacking, in short, is no longer too risky to be contemplated, but is
just risky enough to be titillating.
Rectal STIs predict imminent HIV infection
study from New York has found that a diagnosis of rectal gonorrhoea or
chlamydia is a strong predictor of subsequent HIV infection, regardless of
sexual risk behaviour.
The study found that between
two and three times as many HIV-negative men diagnosed with rectal gonorrhoea
or chlamydia became HIV positive over the following year as men with identical
risk behaviour who did not have one of the two sexually transmitted infections (STIs).
This study’s findings are very
similar to a
European one that found a strong association between STIs (not just rectal
ones) and HIV diagnosis in 2011. The
difference is that the European study found a strong association between having
an STI and already having undiagnosed HIV, whereas the New York one found that
a rectal STI was a predictor of subsequent HIV infection.
In the present study, 276 HIV-negative
gay men attending a clinic in New York, who were diagnosed between 2008 and
2010 with one of the two STIs, were followed for at least one year to see how
many acquired HIV.
Sixty-nine per cent of these
men reported no condom use or inconsistent use. The investigators selected a comparison
group of men who had identical levels of unprotected sex but no rectal STIs.
During the course of the
following year, 11% of the men with rectal STIs acquired HIV compared with 4%
of those without rectal STIs – 2.6 times as many.
One important aspect of the
study was that 70% of the rectal infections detected were asymptomatic and
would not have been detected had participants not attended for a routine STI
Comment: This study strengthens the evidence that rectal STIs
are ‘indicator diseases’ that should indicate an accompanying HIV test, even if
one has been taken recently: UK testing guidelines already state that diagnosis
with an acute STI should trigger the
offer of a test. Given the strong association with subsequent HIV infection,
they could also in the future serve as triggers for an offer of pre-exposure
prophylaxis (PrEP) or other intensified prevention measures. The finding that a
high proportion of infections were asymptomatic also has implications for
efforts to increase the frequency of sexual health screening. Men need to be encouraged
to think about sexual health screening as a regular check-up rather than an
emergency response to an acute STI.
Evidence is not yet sufficient to recommend universal treatment, clinicians and community writers say
do not yet have sufficiently strong evidence to recommend that antiretroviral
treatment (ART) should be offered to all people with HIV, regardless of their
CD4 count, a group of clinical and community writers has concluded.
They criticise the current inconsistency between various
HIV treatment guidelines on when to start ART and add that if all guidelines
used a rigorous standard for rating evidence, their recommendations would be
more consistent and probably more cautious. Universal treatment upon diagnosis,
which two US guidelines now recommend, has been suggested as a way of
controlling the HIV epidemic.
two US guidelines, from the US Department of Health and
Human Services (DHHS) and the International Antiviral Society USA (IAS-USA),
currently strongly recommend that treatment is started before CD4 counts fall
below 500 cells/mm3 and issue a moderate recommendation that it is
offered to people with higher CD4 counts, i.e. everyone diagnosed. They describe
the evidence for treatment by a count of 500 cells/mm3 as ‘strong’.
World Health Organization (WHO) this year decided to recommend treatment at a
CD4 count of 500 cells/mm3 but characterises the evidence for
starting at any CD4 count over 200 cells/mm3 as ‘moderate’.
European AIDS Clinical Society (EACS) and British HIV Association (BHIVA)
guidelines still only recommend that treatment is started at CD4 counts below
350 cells/mm3, and BHIVA says there are "not sufficient data to make
a recommendation" for treatment above this figure.
The writers urge the adoption of a standardised
way of assessing evidence such as the GRADE method used by BHIVA and WHO and say that if
such a rigorous method was adopted, guidelines would probably be more
conservative about when to start HIV treatment.
Comment: The relevance of the
difference between guidelines for treatment is that they create debate about
how treatment should be provided for prevention purposes and who should pay for
it. The US approach seems to be to use ‘expert opinion’ to make the case for a
universal offer of treatment; the WHO and European approach is more cautious,
insisting that we need to await the results of randomised controlled trials
such as START and TEMPRANO before we can make a decision about whether to offer
treatment to people with high CD4 counts.
European HIV prevention webinars: rectal microbicides
We are working with
AVAC to run a series of
webinars (conference telephone calls with synchronised online slides) for HIV
prevention advocates in Europe.
On Thursday 12th
September at 2pm, UK time (BST; 3pm CEST) we will be holding a webinar entitled:
Rectal microbicides: global and
European research and advocacy
- Rectal microbicide
researcher Dr Ian McGowan, of the University of Pittsburgh, on US rectal
- Carolina Herrera from
Imperial College, London: her work is part of the EU-funded microbicide
development programme CHAARM.
researcher Dr Alex Carballo-Diéguez, of Columbia University, on acceptability
- Marc-André leBlanc of
International Rectal Microbicide Advocates (IRMA) on the advocacy agenda for
To register for the webinar and get phone numbers and
joining instructions click this link:
Other recent news headlines
Healthcare workers in the United Kingdom
living with HIV will be permitted to carry out exposure-prone surgical and
dental procedures from April 2014, the Department of Health has announced, if
they are on antiretroviral treatment, receive regular medical monitoring and
have an undetectable viral load. “This change will bring the UK in line with
most other Western countries,” commented the Department of Health.
In a second announcement, the UK health department announced that from
April 2014, self-testing kits
approved by the Medicines and Healthcare Regulatory Authority will be available
for sale to the public. Contrary to some reports, these will not be offered for
free via the National Health Service: local authorities will make decisions on
A study from a rural area in the province of KwaZulu Natal, South Africa,
has found no evidence that providing widespread antiretroviral therapy (ART)
for HIV has led to increased sexual risk-taking in the general population. In
fact, during the period studied, condom use with a regular partner
significantly increased and the proportion of people reporting multiple sexual
partners decreased. This study is important because it is the first to study
sexual risk-taking changes among an entire community when ART starts being provided.
Editors' picks from other sources
from HIV Europe
are delighted to inform you that plans are underway to introduce a new
date in the HIV calendar. HIV in Europe is working towards creating a
European HIV Testing week that will raise awareness of the importance of
early and regular HIV testing amongst those most at risk in the week
ahead of World AIDS Day 2013 – Friday 22 November to Friday 29 November
and bisexual men heading home from a night out in south London are for the
first time to be offered free home-sampling kits to find out their HIV status.
Street teams will offer free kits to home-going clubbers around Vauxhall in the
early hours. HIV home-sampling kits are already available via the internet.
However, this will be the first time they have been handed out directly to a
targeted group on the streets. The aim is to reduce the levels of undiagnosed
HIV in gay men in the capital.
An LGBT policy expert confronts his own fear of being tested for HIV: "Why was I so afraid to be tested? I
knew enough information to understand that death was not my immediate thought.
Quite frankly, though, my biggest fear was not knowing love, but more importantly,
I was afraid that love would never know me. So instead of being courageous and
facing those fears, I wanted to believe that not knowing would be better than
finding out my status."
from Incidence 0
researcher and blogger Roger Tatoud worries that the growing emphasis on HIV
stigma in HIV prevention may be paradoxically reinforcing people's reluctance
to seek testing and treatment, by suggesting that people should feel
stigmatised when they seek HIV testing.
from InSerbia News
More than half of Serbian high school students would continue to
associate with HIV-positive people, a third would not know what to do in such
situation, while only 10 percent would end the friendship, is the result of a
questionnaire answered by more than 1000 students in Serbia, Ministry of
Health announced on Tuesday.
from World News Australia
It is 10 years since the first evidence
emerged of what was until then a completely hidden HIV epidemic among men who
have sex with men in Bangkok, Thailand. Economic expansion and tourism, a
culture of secrecy about sex and HIV, and a history of HIV prevention being
seen largely as a matter for heterosexuals, have conspired to give Thailand one
of the world’s highest HIV incidence rates in gay men – a rate that shows no
sign of declining.