A third of new HIV infections may come from people who are not in continuous care
A number of studies have calculated that a high proportion of HIV infections – the majority of studies say something between a quarter and a half – are transmitted by people who do not know they have HIV. This is one reason why regular HIV testing is being promoted for high-risk groups in many countries.
However, a study from Calgary in Canada suggests that almost as many HIV infections – perhaps a third of the total – could originate in people who do know their HIV status but who for one reason or another have dropped out of care or are moving from one region to another. It also found that the average viral load in people diagnosed but lost to follow-up was nearly as high as in people just diagnosed.
The study found that while people who were newly diagnosed accounted for 37.5% of the community viral load (the total viral load of people with diagnosed HIV), another 33% was accounted for by a mix of people arriving from other areas; returning to care after an absence; moving away; or being lost to care. People who were in continuous care, although representing nearly 80% of all people with diagnosed HIV, contributed less than 30% of the total viral load within the HIV-positive community.
The researchers first looked at diagnosis and viral load trends between 2001 and 2011. It found that while the proportion of people with viral loads under 50 copies/ml doubled from 32 to 66%, the mean viral load per patient in care did not significantly change: it was 32,000 copies/ml in 2001 and 30,000 copies/ml in 2010. The reason for this apparent paradox was that over the decade, as a higher proportion of those in care were put on effective HIV therapy, people with detectable viral loads were more and more likely to be people who had either just been diagnosed or returned to care after a gap.
This study implies that more intensive tracing and follow-up methods could potentially make as big a difference to HIV transmission rates within local communities as increased testing rates
Comment: This is an important study because it quantifies, in some detail, something that was long suspected: ongoing HIV transmission in high-risk populations is not just sustained by people who do not know their status, but also by people who do and for one reason or another have dropped out of care or moved. Studies presented at the 2013 Conference on Retroviruses and Opportunistic Infections (CROI) were already suggesting this might be the case, as did a study of community viral load in France.This reinforces the theory that retaining people in care and tracing those who drop out of care is as important as persuading them to test in the first place.
PrEP news: recruitment and adherence in open-label trial; adherence and risk factors in drug users’ trial
The 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2013) heard several presentations expanding our knowledge of the potential of pre-exposure prophylaxis (PrEP).
The conference heard the first data from iPrEx-OLE, where OLE stands for Open-Label Extension. In this study, participants in the original iPrEx placebo-controlled study of tenofovir/FTC PrEP in gay men and transgender women, which reported an overall efficacy of 44%, were invited to join an extension study in which they all received tenofovir/FTC.
Of the 2340 people eligible to join iPrEx-OLE, 1526 (65%) said they wished to enrol and 1038 (44%) actually started taking PrEP. By far the most common reason for not continuing was concern about side-effects: 49% who did not continue said this was a concern.
Drug-level monitoring was done as part of the study, and detectable drug levels were found in 61 to 71% of the study participants (whereas it was only found in 50% of participants in the placebo-controlled trial). Asked if he was disappointed that about 29% of participants in the original study both elected to continue into iPrEX-OLE and take the study drug, principal investigator Bob Grant pointed out that iPrEx-OLE participants could stop and restart PrEP in consultation with researchers.
In another presentation, Michael Martin of the US Centers for Disease Control gave additional data on the study of tenofovir-based PrEP among people who inject drugs in Bangkok, Thailand. The main results from this trial were published in June: the study found 49% fewer HIV infections in participants taking tenofovir than those taking a placebo.
Drug levels were measured, and efficacy was 70% in participants with detectable tenofovir in their blood, compared with only 23% in people with none. In participants with 90% adherence – as measured by drug levels – efficacy was 68%, and it was 72% with 95% adherence.
In terms of the association between risk behaviours and HIV infections, sharing needles was associated with an 8.9-fold greater risk of infection; having been in prison with a 2.7-fold risk; and being under 30, compared with over 30, with a 1.9-fold risk. In contrast, no sexual risk factor was significantly associated with seroconversion.
Comment: The adherence and efficacy figures reported from these trials are unsurprising and relatively reassuring. The importance of injecting drug use as the predominant risk factor in the Bangkok trial provides at least indirect evidence that PrEP really does work against HIV transmissions resulting from shared injecting equipment. What is less reassuring is the relatively low rate of people who elected to go on to the open-label extension of iPrEx, and the high rates of concern about side-effects. This indicates a need for up-to-date information on the safety of the latest antiretrovirals, but also that, as Bob Grant told the conference, “PrEP simply is not for everybody”. Some may become more interested if the promise of a long-lasting injectable formulation – also aired at IAS 2013 – becomes a possibility.
Cancer vaccination could help older gay men too
Gay men of all ages, with and without HIV, could benefit from being vaccinated against human papillomavirus (HPV), which causes anal, penile and some oral cancers, as well as cervical cancer in women.
Two HPV vaccines are licensed for use, after trials showed they were highly effective. Most European countries have introduced vaccination programmes for adolescent girls, with varying degrees of coverage. For example, in the UK, girls aged 12 to 13 have been routinely offered an HPV vaccine since 2008, and a ‘catch-up’ strategy initially included girls up to the age of 18. From 2008 to 2012, the UK’s programme used the vaccine Cervarix; since 2012, it has used Gardasil.
The US and Australia have also licensed Gardasil for use in boys in the last two years. Gardasil protects against the two most common strains of HPV, types 6 and 11, and against types 16 and 18, which cause the majority of cases of cancer (Cervarix protects against HPV 16 and 18).
One argument against vaccinating men has been that a high proportion of gay men, especially ones with HIV, already have the HPV types the vaccine protects against. There was an assumption there was no point in offering them the vaccination, as it has no effect on symptoms in those already infected.
However, it is becoming clear that HPV infection is not lifelong. The body eventually gets rid of the virus and its cancer threat (this happens more slowly in people with HIV, which is partly why they have higher rates of cancers). Vaccination against HPV could protect against reinfection.
A study from Australia, presented at IAS 2013, found that 30% of a group of HIV-positive and -negative gay men aged 35 and older had HPV 16, the most common and virulent cancer-associated type.
However, it also found that these men were acquiring new HPV 16 infections at the rate of 5% a year and any of the four types covered by Gardasil at 20% a year.
Assuming that it is possible to find gay men who are in between getting rid of one HPV infection and being infected with the same subtype again, this implies that giving all gay men Gardasil could offer a significant degree of protection against genital warts and HPV-related cancers.
A new multivalent vaccine covering nine subtypes of HPV is being developed and the study found that it might protect up to 27% of gay men over 35 against reinfection with HPV per year.
Comment: The evidence that HPV vaccination may benefit a wider range of people than originally thought has slowly accumulated since the vaccines’ introduction. The UK’s Joint Committee on Vaccination and Immunisation (JCVI) is deliberating on whether to authorise HPV vaccination for boys/men, and is awaiting evidence on cost-effectiveness. The UK’s largest HIV charity, the Terrence Higgins Trust (THT) and the British Association for Sexual Health and HIV (BASSH), are among those lobbying for change, and recently attracted vocal support from a British MP. Gay men suffer from having a high risk of anal cancer but being a relatively small population in this sort of consideration.
Eastern European and migrant gay men have poorer access to HIV prevention
A substantial minority of men who have sex with men (MSM) in countries including Cyprus, Serbia, Lithuania, Ukraine and Hungary are not being reached by HIV prevention programmes and have gaps in their understanding of HIV, according to a report from the European MSM Internet Survey (EMIS), which surveyed around 180,000 gay and other MSM from all round Europe in 2010, and released its final report in May.
A series of questions assessed respondents’ knowledge of HIV testing and transmission; other sexually transmitted infections (STIs); and post-exposure prophylaxis (PEP). Knowledge of testing was high and of transmission routes quite high, but a third of respondents lacked knowledge about STIs and 70% had poor knowledge of PEP. The composite mean of all knowledge scores was generally lower in east and south-east Europe.
Turkey had particularly low scores in all of the knowledge areas (62%) as did Romania, Cyprus, Latvia and Lithuania. But Poland, Croatia and Bosnia had higher scores than similar countries while Ireland, Finland and Greece had poorer ones.
Respondents were also asked about access to HIV testing, condoms and prevention information. Overall, 91% were confident of their ability to get tested for HIV. The poorest scores were in Turkey (73%), and in Cyprus and Serbia (both 80%).
Men were also asked if they had had unprotected anal intercourse in the past year solely because they did not have a condom to hand. This was the case for 14% of respondents overall, but 30% and 20% of Norwegian and Spanish respondents respectively. This suggests that condom availability is as serious a problem in Norway and Spain as it is in Turkey (32%), Macedonia (28%), Moldova (25%), Serbia (23%), Cyprus (23%) or Romania (20%). Russia, Slovenia, the Czech Republic and Hungary had relatively good scores for condom availability.
Migrants from outside Europe were significantly less likely to be reached by prevention services. Men born in south-east Asia had a composite knowledge and access score 42% lower than average and men born in Latin America or the Caribbean a 37% lower score.
A second section of the EMIS report shows that, across Europe, 58% of gay men report at least one incident of unprotected anal intercourse in the past year. Whereas 39% of men had had unprotected sex with a steady partner, 26% had done so with a casual partner.
Comment: This is one of a number of analyses of parts of the huge EMIS project report, several of which have been featured in the last two issues of this bulletin. The correlation between HIV prevention knowledge and HIV prevention-method availability is very tight: poorer availability of HIV programmes targeted at MSM translates into poorer knowledge of HIV and STI transmission and prevention. The condom use findings essentially duplicate what a number of other studies from the UK, US and Australia, and some other countries, have found: while a majority of gay men do use condoms, only a minority manage to maintain 100% condom use.
Malaysia’s harm reduction is working, but reaching too few people who inject drugs
The IAS 2013 conference heard that an expansion of methadone maintenance and needle exchange programmes in Malaysia, a conservative Muslim country not previously noted for its liberal policies on drug use, has already averted around 3000 HIV infections. The programme is highly cost-effective, although coverage remains too low, police harassment prevents effective implementation, and broad political or public support for the policy is lacking.
Dr S Subramaniam, the Malaysian health minister, told the conference that the country’s adoption of harm-reduction programmes in 2006 was determined by the scientific evidence. “Desperate times call for bold measures and our HIV/AIDS epidemic at the time was spiralling out of control, being largely driven by injecting drug use,” he said. “We knew that clean needle exchange and methadone had worked successfully, in so many countries, in reducing new HIV infections.”
Malaysia has around 80,000 people living with an HIV diagnosis. Whereas there were around 6500 new diagnoses each year a decade ago, this figure has now dropped to around 3500. Moreover, the proportion of new diagnoses attributable to injecting drug use has fallen from around 70% a decade ago to 35% today.
Although there has been a considerable expansion of harm-reduction programmes since 2006, coverage remains limited. Around one-in-four injecting drug users are registered with methadone maintenance programmes and only one in five are reached by needle and syringe exchange programmes.
Ragunath Kesavan of the Malaysian Bar Council told the conference that one barrier to further implementation of harm reduction was that the public have been told for decades that the solution to the problem of drug abuse lies in stricter laws and tougher enforcement.
Comment: Malaysia is a good example of a country with a culturally conservative and indeed punitive attitude towards drug use that was forced by the evidence to accept that opioid substitution therapy and needle exchange were worth adopting. As the last remark reminds us, it can take a very long time to turn round entrenched and accepted attitudes toward HIV and at-risk populations.
Nearly one-in-four HIV-positive gay men cured of hepatitis C is reinfected
There is a high incidence of hepatitis C virus (HCV) reinfection among gay men living with HIV in London, results of a study published in the online edition of AIDS show. The research, which involved men with HIV and HCV co-infection, who cleared their primary HCV infection spontaneously or after treatment, found that 22% of study participants were subsequently reinfected with HCV and a small number of men as many as three times.
In the 145 men who had a documented date of initial HCV infection, there were 32 reinfections and they had a hepatitis C incidence (reinfection) rate of 8% a year. Eight of the 32 men who were reinfected were reinfected with HCV a second time. This yielded an incidence rate of 23.2 per 100 person-years. The median time to second reinfection was 1.5 years.
Analysis of the entire cohort found 54 reinfections in total, combining first, second and third reinfections.
Overall, 20% of the men spontaneously cleared their reinfection. The treatment response rate among men undergoing therapy for reinfection was 73% for men with genotypes 1 and 4 and 100% for genotypes 2 and 3.
“The majority of reinfections were treated in the acute phase of the infection…and [cure] rates were consistent with studies treating acute HCV infection in HIV-positive MSM,” explain the authors.
“We recommend enhanced surveillance of patients who have cleared HCV infection to allow the early detection and treatment of any reinfection,” the investigators conclude. “In addition, we recommend directed education and prevention interventions to HIV-positive MSM with HCV infection.”
Comment: A reminder that the health needs of gay men at risk of hepatitis C do not go away when they are cured. Much more consistent and simple transmission and prevention information is needed for this population. NAM recently published clear information on sexual transmission for gay men: How hepatitis C is passed on during sex.
European HIV prevention webinars: rectal microbicides
The webinar series is taking a break in August and the next one is currently planned for Thursday 12 September.
The topic is rectal microbicides and speakers provisionally include Dr Ian McGowan from the University of Pittsburgh and Marc-André le Blanc of International Rectal Microbicides Advocates (IRMA).
Other recent news headlines
First-ever community-randomised combination prevention trial produces modest drop in HIV incidence, big increase in testing in men
How do HIV prevention programmes impact on a whole community rather than individuals? This has been a very difficult question to answer but the recent IAS 2013 conference heard the results of Project ACCEPT, the first-ever community-randomised HIV prevention trial. Matched but geographically separate areas were randomised either to receive standard voluntary counselling and testing or an enhanced programme of community mobilisation and mobile testing. The result was a modest 14% drop in HIV incidence in communities receiving the enhanced programme but a much larger drop among older women and a near-doubling of the HIV testing rate in men.
A single community testing site is testing over a third of the gay men newly diagnosed with HIV in Catalonia, Spain, and is able to link almost all of the newly diagnosed men to treatment services, project co-ordinators reported to the IAS 2013 conference.
Set up in 2006, BCN Checkpoint was one of the first community testing projects for gay men in Europe. Rapid, point-of-care tests are performed by non-medical volunteers and staff at a dedicated location in Barcelona’s gay district, open each day until 8pm.
A study of HIV testing and diagnosis in gay men in France found that one-in-five infections (21%) diagnosed were found to be very recent, in the acute HIV stage. It found that although only 15% of diagnoses were in men who previously tested less than a year ago, 42% of recently acquired HIV infections were in this group. Karen Champenois of the French national research agency INSERM told the IAS 2013 conference that, although France has quite low rates of undiagnosed HIV (only 19% do not know their status), HIV incidence in gay men is not declining. She added that whereas most chronic infections were self-referrals, in the majority of acute diagnoses the HIV test was suggested by a health practitioner.
A study of a trial of pre-exposure prophylaxis (PrEP), which failed to show any effect, suggest it may have failed because women joined the trial for reasons other than PrEP – namely having a monthly test for HIV. Qualitative interviews with participants showed that the participants used the test, and participating in the trial itself, as a way of getting reassurance that they did not have HIV. The trial itself, in the minds of the women, became the prevention method offered. “It’s magical thinking,” presenter Christina Wong of FHI 360, who co-ordinated the trial, commented to aidsmap.com. “We should discuss how to better incorporate participants' reasons for trial participation into trial design,” she said.
Editors' picks from other sources
from IRIN Plus News
Consistent increases in HIV infections in the Philippines cannot be reversed without appropriate interventions, say health experts, following the recent release of the country's highest monthly infection rate recorded thus far. Not enough prevention interventions reach men who have sex with men and injecting drug users.
from Huffington Post
Thirty years of HIV prevention efforts and advocacy have enabled many men living with HIV to be open about their HIV status. But while we have been inundated with messages telling us to "talk about HIV with your sex partners," for some such discussions are fraught with anxieties over blame, judgment, abandonment – or surprising gaps in knowledge.
Research on opinions about rapid HIV home testing among gay men has found it could be an effective risk reduction and HIV prevention tool.
from Mapping Pathways
This 10-minute podcast was produced by AIDS Foundation of Chicago (AFC), the second in a series of discussions inspired by "Developing Evidence-Based, People-Centred Strategies for the Use of Antiretrovirals as Prevention." Jessica Terlikowski and Jim Pickett chat about PrEP.
from Pink News
Tory MP Mike Freer has announced a campaign to have the HPV vaccination extended to include teenage boys, arguing that the current scheme, which only vaccinates girls, neglects to protect gay men.