Jane Takes a HIV Lead

posted: 16/03/2011

The discovery of HIV in 1981 sparked widespread panic and a media frenzy. But 30 years on, one of London’s leading London HIV doctors, Professor Jane Anderson, knows that keeping HIV in the public eye is now much harder.
 

Jane is the director of Homerton Hospital’s Centre for Sexual Health and HIV – she happens to be married to TV wit Clive Anderson – has watched the HIV changes over the years.

New Chair for BHIVA

She takes over as Chair of the British HIV Association this spring.
 

“I qualified as a doctor just at the beginning of the AIDS epidemic,” she said. “We didn’t know about HIV. We just knew about the [gay] men who were dying. When I first started, we were giving people huge quantities of drugs to take home – like shoe boxes full of the most revolting potions. If you told me then that we would have one pill to be taken once a day in the course of my career – not even my lifetime – I would have said absolutely not.”
 

She began working at the Homerton in 1990 after setting up the HIV unit at Barts hospital in London.

The Homerton had just 35 HIV positive patients back then. Now the Homerton hospital HIV team care for 820 people. Survival rates have hugely improved with the development of combination treatment of antiretroviral drugs in the mid 1990s, which has transformed HIV into a lifelong, but manageable, condition. People can have a good and long life now with HIV.
 

Treatment success
Patients aged 35 when infected can expect a further 35 years of normal life, and the team at the Homerton ensure the babies women with HIV may have are HIV-negative.
 

Stigma still a testing barrier
But despite the medical advances, one barrier still remains. “There’s a frustration with the stigma and the fact that people are still reluctant to get tested,” said Jane. “It is one of those things –you know that you have got the solution in your hands but people are too afraid to come and take it. To have come this far and to still find people won’t talk about it – this is where medicine meets reality.”
 

Undiagnosed means treated late

The number of people living with HIV nationally reached an estimated 86,500 in 2009. But more than a quarter – almost 22,500 – were still unaware of their infection, according to the Health Protection Agency. In many HIV clinics around one quarter of all HIV diagnoses are at a late stage of infection, when permanent damage has already been done to the immune system. Most deaths from HIV in the UK are among the people who were late coming for medical help.
 

The Homerton hospital has some celebrity supporters - actor and comedian Stephen Fry, who filmed part of a HIV documentary at the hospital, as well as Jane’s husband, the former barrister and television presenter Clive Anderson, who are not afraid to take a public stand.
 

Jane and Clive met in 1979 and will be celebrating their 30th anniversary this year.
“He is incredibly supportive. He has always been up for helping,” said Jane. “I’m always coming along with another request and he always says yes.”
 

Source

Guide to Safer Sex Advice

posted: 01/03/2011

The British HIV Association has produced draft guidance for STI clinics on offering Safer Sex Advice for the UK. They are inviting comments on their draft Guidelines.

The Safer Sex Advice guidelines recommend behaviour change interventions, what safer sex advice to give people at risk of STIs, and advising people living with HIV and people at greater risk of HIV infection.

The guidance is also useful for GPs and HIV care services when offering Safer Sex Advice.
 

Comment on Safer Sex Advice Guidance

Comments deadline is 31 May 2011 - comment through this webpage

Safer Sex Advice Guidance for the UK

Treating HIV-2 Guidelines

posted: 04/11/2010

There are two main types of HIV, and HIV-2 is found mainly in West Africa and less so in parts of India, with very few migrants in the UK having this HIV type; most people in the UK have HIV-1.

The first treatment guidelines for HIV-2 have now been agreed by BHIVA (British HIV Association).
 

Under 150 people are diagnosed with HIV-2 in the UK and under 50 people have both HIV-1 and HIV-2, so these guidelines try to make sure the considerable differences between the two HIV types and the best treatments for HIV-2 are well understood.
Although HIV -1 and HIV-2 are closely related, there are some big differences in testing, monitoring viral load, in treatment.
 

Less transmission and health harm
HIV-2 is harder to pass on, because it is 5 – 10 times less infectious in heterosexual sex than HIV-1 is. Women are also less likely to pass on HIV to a baby: this is 20-30 times less likely with HIV-2. The assumption is that HIV-2 can also be passed on through sex between men and injecting drug use, like HIV-1.
 

HIV-2 is also less harmful than HIV-1. Death rates are far lower, people show no HIV symptoms for far longer (10 - 20 years without symptoms is not unknown) and some people may never develop AIDS. But HIV-2 also varies and some people will become ill as fast as they would have with HIV-1.
 

Testing
Standard HIV tests find people with HIV-2 but because dealing with HIV-2 is different to HIV-1, people with HIV-2 need to spotted during testing. Not all UK labs can test for HIV-2 but testing for HIV-2 needs to be done for people to be given proper treatment and care. There are special tests to identify people with HIV-2.
 

Measuring the viral load of people with HIV-2 is a problem. Different tests give different results. HIV-2 viral load is harder to find because it is about 30 times lower than with HIV-1: viral load is much more likely to be undetectable. There are no commercial HIV-2 viral load tests for sale.

Viral load is not detectable in half the people with a CD4 count of 300. The higher the CD4 count, the less likely it is that any HIV-2 viral load will be found. The CD4 counts and viral loads of people with HIV-2 have to be interpreted quite differently to people with HIV-1. There are four specialist labs in the country that can do this.
 

Treatment
Where HIV-2 viral load is undetectable the CD4 count may be the only guide to when to begin treatment. CD4 counts can remain stable for years. But CD4 can also fall as fast as with HIV-1, when a HIV-2 viral load is high. CD4 counts tend not to bounce back upwards as much after treatment as with HIV-1.
 

The BHIVA Guidelines for HIV-2 advise clinicians to refer all HIV-2 patients to someone expert in treating HIV-2. Most HIV doctors in the UK don’t have the necessary experience, and interpreting test results is a problem.
 

BHIVA’s treatment guidelines for HIV-2 describe how it responds to the various types of HIV drug. They suggest preferred first and second line treatment combinations for HIV-2 and the use of two NRTIs and one or more PIs. Second and third line options are limited. A good number of HIV drugs are not effective with HIV-2 and these must be avoided. Where people have both HIV-1 and HIV-2, treatment choices are limited and should be considered carefully.
 

When to treat
They suggest starting treatment before the CD4 count falls to between 350-500, and treating people whenever the VL is above 1000.
 

Source HIV Medicine (2010) 11, 611-619: the November issue and soon online

More HIV Testing Urged

posted: 08/10/2010

The NHS health advice body NICE has produced its first HIV guidance, about HIV testing. The draft HIV testing guidance recommends that mainstream health services offer much more HIV testing to the two communities most affected by HIV in England, black African people and to men who have sex with men. The guidelines also call for more testing to be offered in places such as bars and saunas, using rapid point-of-care tests.
 

NICE HIV testing: open for comments
The National Institute for Health and Clinical Excellence (NICE) tells the NHS which are the best and most cost-effective treatments and public health interventions. NHS bodies are legally required to fund the medicines and treatments recommended by NICE.
 

Making HIV testing guidelines work
Other organisations have produced HIV testing guidelines before, notably the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASHH). But these were not backed by the UK National Screening Committee, nor by NICE, and many parts of the NHS simply ignored them.

The most recent BHIVA and BASHH testing guidelines recommended that HIV testing should be offered in a wide range of healthcare settings, including GP surgeries and most hospital departments. Little was done about this.
 

NICE will force more testing action
To increase testing, the Department of Health asked NICE to produce public health guidance to increase HIV testing both among men who have sex with men and among black African communities. The new NICE guidance supports most of the BHIVA and BASHH testing recommendations, and goes further with some recommendations.
 

There are two guidelines - one to increase testing in men who ave sex with men, and a the other for increasing testing among black African people.
 

Local strategies needed

For both men who have sex with men and for black Africans in England, NICE recommends preparing local strategies to increase HIV testing, developed in consultation with community organisations and the people affected. These strategies should focus on sections of the community who are less likely to use services. Community engagement and involvement is particularly important for black African communities.
 

Africans - involve people as champions and leaders
NICE recommends that black Africans in England should be recruited and trained to act as ‘health champions’ and ‘role models’. HIV testing work must deal with people’s misunderstandings and ignorance about HIV, testing and treatment, and must promote the benefits of early diagnosis and tackle HIV-related stigma.
 

The guidance for black African communities includes providing HIV testing outside sexual health clinics. This is because the evidence from the literature is that HIV testing in sexual health clinics is seen by some black Africans as stigmatising, complicated and time-consuming, while HIV testing in other healthcare settings was welcomed.
 

NICE recommends that general practitioners should routinely offer an HIV test to black Africans who have not tested before or who have had a new sexual partner since the last negative test. In hospitals and other healthcare settings, an opt-out test should be routinely provided to black Africans who are having blood taken for other reasons.
 

Testing in sex venues to reach gay men
Health promotion interventions promoting testing to men who have sex with men should include venues, such as saunas, clubs and cruising areas, or websites, which facilitate sex between men.
NICE appears more enthusiastic than BHIVA about community testing in sex on the premises venues. In gay venues, NICE says rapid tests (using mouth swabs or finger-prick blood samples) should be provided by trained staff, in a secluded or private area.
 

NICE’s guidance for men who have sex with men encourages testing in primary care (GPs), but not in secondary care (hospitals). The BHIVA guidelines are different, and recommend that all healthcare settings should offer an HIV test to any man who says he has sex with other men.
 

NICE recommends that GP surgeries should recommend all males to have HIV tests where the surgery is in an area with a large gay community or theer is a high rate of HIV.
 

Carl Burnell, of the gay men’s health charity GMFA, questions whether this will is work, because of the many other demands on GP surgery capacity. “The strategy assumes that other services are running like clockwork and have capacity to offer HIV testing,” he said.
 

Clear path from testing to services
All testing services need clear pathways for people to obtain any necessary confirmation of the HIV test result, HIV treatment services and HIV support groups. People who test negative may need help through counselling and safer sex interventions.
 

The draft guidance comes before results are published on several Department of Health funded pilot projects evaluating new testing strategies.
 

NICE’s guidance is open for feedback and comments until late November. The final NICE HIV testing guidance will appear in March 2011.

HIV testing guidelines for MSM 

HIV testing guidleines for black Africans in England
 

Source

Over 50s - 1 in 12 new diagnoses

posted: 04/05/2010

One in twelve new HIV diagnoses in the UK are in people over the age of 50. Late diagnosis is common among over 50s but almost half of these people were infected after their 50th birthday.

Between 2000 to 2008, one in twelve new adult HIV diagnoses were in a person over the age of 50. The numbers increased year on year, from 304 in 2000 to 787 in 2008.

Typically - male, gay, white, older
The profile of people diagnosed over 50 is rather different to those diagnosed younger. They are more likely to be male, homosexual and white. Older heterosexual men often got HIV in southeast Asia – usually in Thailand.

Infected after 50 – Prevention’s still needed
By looking at the CD4 count when the people were diagnosed, the researchers were able to estimate how long before diagnosis each person had HIV. Just under half (48%) were infected after the 5oth birthday. HIV prevention cannot ignore older adults.

Late diagnosis is big – some deaths within one year
Nonetheless, late diagnosis is more of a problem in older adults than in younger groups. A total of 48% are diagnosed with a CD4 count below 200 cells/mm3, compared to 33% of people under 50. In gay and bisexual men, double the number of over-50s are diagnosed late compared to younger men (40% and 21% respectively).

Moreover, these late diagnoses make a substantial contribution to short-term mortality. Amongst people diagnosed over the age of 50, 14% of those diagnosed late died within a year, compared to 1% of people not diagnosed late.

Whereas people over the age of 50 represented 11% of the individuals accessing HIV care in 2000, they now make up 17% of those doing so.

More on over 50s in Brighton
The Manchester BHIVA/BASHH conference also heard about the treatment and care needs of older adults. One poster profiled 257 patients aged 50 or over attending HIV services in Brighton. The vast majority were white gay men, their mean age was 58 and they had lived with HIV for an average of 12 years.

85% had at least one other health problem, with 43% having three or more. As a result, in addition to anti-HIV drugs, two-thirds were taking medication for other conditions (12% reported five or more other drugs) and 79% were under the care of other medical specialists (dermatology, ENT, cardiology, gastroenterology, etc,). The authors recommended that HIV clinicians should work in close co-operation with these other specialists.

More tests and reviews

Another conference poster highlighted the importance of carrying out additional tests and assessments, for example for prostate cancer and other malignancies. Moreover regular review of all medication is required to monitor possible drug-drug interactions.

Brighton men speak

Finally, the Brighton researchers also presented findings from 20 in-depth qualitative interviews with people with HIV aged between 52 and 78 (mean age 64). Almost all were white gay men.

Some of the key themes were:

• Health: concerns about the unknown effects of HIV and antiretroviral treatment over time; the number of co-morbidities; a desire to have continuity of medical care and more psychosocial support. “Obviously the antiretrovirals are keeping me alive but there must be some long-term damage,” said one interviewee.
• Survival: stories of outliving peers and of not having prepared for the future because none was expected. “They’re all dead and I’m the only one left alive and I’ve got no pension.”
• Self-esteem and rejection, linked to a youth-orientated gay scene, changes in physical appearance and sexual dysfunction. “Who wants an old faggot like me?” was one comment from the interviews.

Advice and Information 

Coming of Age - a guide to ageing well with HIV - 130 pages, UK, 2010

download is free - it is large (2.8 Mb) pdf file, so please be patient while it downloads  

Ahead of Time: A practical guide to growing older with HIV, Austrailia, 2010

Older Adults with HIV - The ROAH study of 1000 adults over 50 by ACRIA, New York

Sources and references