International HIV Sidelines Gay Men

posted: 07/03/2011

Every two years the world’s biggest HIV conference faces criticism for sidelining the needs of gay men, sex workers, transgender people, and injecting drug users. The International AIDS Society conference visited Vienna in 2010, around 25,000 people attended, but it still grossly under-represented four groups most at risk for HIV infection.

A detailed study by the Global Forum on MSM & HIV (MSMGF), confirms the long-held suspicions and criticism of this neglect, and calls for change.

The International AIDS Society may be part of the problem, but it can solve it.

Shame of stigma and discrimination
Stigma and discrimination against marginalised and unpopular groups affected by HIV is unprofessional and brings shame on the International AIDS Society.

The 2010 conference programme seriously neglected key needs. There is little exclusive time and exposure given to the four groups, and the four groups are often ignored even in general studies.  

• Only 6.6% of the abstracts of studies were only concerned with gay and bi men / MSM, 5.7% targeted only people who use drugs, 3.5% looked only at sex workers, and 0.6% solely considered transgender people.
• Only 3.8% of ordinary conference sessions exclusively focused on gay and bi men / MSM, 5.1% on IDU people, 2.5% on sex workers and 0% on transgender people.
• Just 3.7% of all workshops exclusively focused on gay and bi men / MSM, 6.4% on people who use drugs, and 0% on sex workers and 0% on transgender people.
• Out of over 4,500 abstracts sent in for selection and publicity, only 558 even mentioned MSM, only 442 mentioned IDU, just 338 mentioned sex workers, and a bare 134 mentioned transgender people.
• Only 2.6% of all sessions in the entire conference programme exclusively focused on MSM, 4.5% exclusively focused on IDU, 3.0% on sex workers and 1.1% on transgender people.

The percentage of all sessions at the conference exclusively focused on the four marginalised groups was 2.6% for MSM, 1.1% for transgender people, 3% for sex workers and 4.5% for people who use drugs.

Research shows these four populations are at higher risk for HIV than the general population in nearly every country where reliable data exist.

Compare tiny conference gestures with actual needs

• MSM represent more than a quarter of HIV infections in Latin America and the Caribbean
• People who inject drugs are more than half of HIV infections in Eastern Europe
• Up to half of all sex workers across Sub-Saharan Africa have HIV
• Transgender people in El Salvador, Indonesia and India have HIV rates as high as 25%, 35%, and 42% respectively.

"Abysmal representation reinforces discrimination and invisibility"

“While the International AIDS Society turns a blind eye, HIV rates among these populations continue to climb around the world,” said Dr. George Ayala, Executive Officer of the MSMGF.

“The IAC is the world’s most important opportunity for international exchange and collaboration on HIV and AIDS. Such abysmal representation of most-at-risk groups only serves to reinforce the invisibility, discrimination and disregard that drive the epidemic among these communities.”

“Ostensibly, the IAC offers chances for local healthcare providers to learn ways to improve their services, provides channels for advocates to engage in dialogue with powerful decision-makers, and creates opportunities for community members to shape global funding and research agendas,” said Dr. Mohan Sundararaj, Policy Associate at the MSMGF. “This really is a phenomenal platform, but how useful can it be when those who need it most are locked out?”

Calls for change
The report recommends steps to make the Conference programme fairer, based on the numbers of people affected . These include involving the communities affected in the conference planning.

“The International AIDS Conference has unparalleled potential to impact the global AIDS epidemic,” said Dr. Ayala. “It is incumbent upon the organizers to ensure that the IAC becomes a vehicle for change, shifting the global landscape so that funding, research and programs are directed to those who need them most. Right now it’s part of the problem.”

Source The Global Forum on MSM & HIV

Read the full report Coverage of Four Key Populations at the 2010 International AIDS Conference: Implications for Leadership and Accountability in the Global AIDS Response February 2011

The Global Forum on MSM & HIV (MSMGF) is an expanding network of AIDS organizations, MSM networks, and advocates committed to ensuring robust coverage of and equitable access to effective HIV prevention, care, treatment, and support services tailored to the needs of gay men and other MSM. Guided by a Steering Committee of 20 members from 18 countries situated mainly in the Global South, and with administrative and fiscal support from AIDS Project Los Angeles (APLA), the MSMGF works to promote MSM health and human rights worldwide through advocacy, information exchange, knowledge production, networking, and capacity building.

About 1 in 10 have Hepatitis C

posted: 15/02/2011

9% of people living with HIV in the UK also have hepatitis C, the Journal of Viral Hepatitis tells us, which is low compared with other countries.  “In comparison with other large cohort studies, the overall HCV [hepatitis C virus] prevalence of 8.9% in the UK…is low,” comment the investigators.

9% means there are about 6,000 people who are diagnosed with both HIV and hepatitis C in the UK.

But 13,000 more people with HIV still haven't been checked for hepatitis C.

George House Trust analysis suggests that the true UK rate of hepatitis C among people with HIV is probably 11%, not 9%.

As a result, 2% of UK HIV clinic patients receive substandard care - we estimate there are around 1300 people with hepatitis C that is ignored by their HIV clinic, simply because the clinic hasn't checked for it, despite guidance advising hepatitis C checks since 2004.

Are you curious why the hepatitis C rate is lower in the UK among people with HIV? Here, most drug injectors (the main group of people who get hepatitis C) do not have HIV.

Early in the epidemic, England did the right thing, by introducing harm reduction for injecting drug users - like providing clean needles and syringes to reduce onward HIV transmissions. 

Countries which delayed doing this have higher rates of HIV now among injecting drug users. We are sorry to say that Scotland is one of the countries with higher rates of hepatitis C among people with HIV.

1 in 10, or even 1 in 9?

The level of hepatitis C must be above 9%, because about 20% of UK people with HIV have never been tested for hepatitis C, despite clear UK guidance to test everyone with HIV for this once a year. 

The 20% of people untested for hepatitis C by clinics would, if tested, probably add another 2% to the total, meaning the actual rate of hepatitis C among the UK HIV+ population is about 11%.  

Liver disease harm means hepatitis C matters

Liver disease caused by hepatitis C is a major cause of illness and death among people with HIV. What was uncertain was

• how common hepatitis C is among people with HIV in the UK now,
• whether people were being checked every year for hepatitis C following the guidelines, and
• how well treatment works when people have both HIV and hepatitis C.
   

So, the study used anonymous information about 31,765 people using ten HIV clinics between 1996 and 2007, from the UK Collaborative HIV Cohort (UK CHIC).
 

1 in 5 seen at HIV clinics in 2007 were untested

The proportion of patients screened for the virus increased from 9% in 1996 to 80% in 2007. 
 

“There has been a clear instruction that all HIV-positive patients should be screened since at least 2004,” write the investigators. Nevertheless, “20% of patients under follow-up in 2007 had not apparently ever been tested. The latest BHIVA [British HIV Association] guidelines recommend screening all HIV-positive patients at diagnosis, with annual repeat testing in those who are negative.”
 

Although injecting drug use (IDU) is very closely linked with having hepatitis C, only half (50%) the people with a history of injecting drug use were known to have had a hepatitis C test.

Gay men with HIV were most likely to have had a hepatitis C test (74%), followed by heterosexual men and women (63%), then IDU (50%). The investigators think more drug injectors have been tested than the 50% they found, perhaps at services for drug users.

George House Trust commentary

In 2009, 65,319 HIV-infected individuals (of all ages) were seen for HIV care in the UK, so the 2% who clinics are not treating for hepatitis C means about 1300 people are being neglected with worryingly substandard care. 

• Clinics admit they don't know the hepatitis C status of half the people with HIV infected through injecting drug use. From this study we know that 84% are very likely to have hepatitis C.
• Clinics don't know the hepatitis C status of 26% of gay men, the next most at risk group. We know from this study that 7% of these men probably have hepatitis C.

The failure to screen 20% of HIV clinic patients for hepatitis C harms people's health and can seriously shorten life. Hepatitis C causes permanent liver damage.

Anyone with hepatitis C and HIV needs careful health monitoring for both conditions and the coordination of treatment and care.

This isn't happening for half the people infected through IDU and about one third of gay men, the other main group at risk.

The 9% of people with HIV in the UK this study found to have hepatitis C, compares with just 0.44% among the general UK population.
 

Hepatitis C and how people got HIV
The rate of hepatitis C varies with how people got infected with HIV. 84% of the people who got HIV as an injecting drug user have hepatitis C, and the next largest group is gay men – but just 7% of HIV positive gay men also have hepatitis C.
 

Gay men injecting more?
However, the investigators suggest that some hepatitis C infections in gay men may be due to injecting drug use, which is “underreported by some MSM [men who have sex with men], sufficient to place them at risk of HCV infection … underreporting of IDU as a risk for HCV transmission in MSM may also affect other cohorts.”
 

Unsurprisingly (when most gay men in the UK are white and most injecting users are also white and male), most people with both HIV and hepatitis C are men (80%), white (82%), with the median age at 37.
 

Treatment working
4% of the 10,000 patients starting HIV treatment after 2000 also had hepatitis C. Overall, 91% reached an undetectable viral load, which is as good as for people with only HIV. 
 

Ask for hepatitis test when your next bloods are taken

Jason Warriner, clinical director of Terrence Higgins Trust said: “It’s concerning that almost 13,000 people living with HIV could have Hepatitis C without knowing it because they haven’t been routinely checked for the infection.

It’s not just people who use drugs intravenously who’re at risk of Hepatitis C, the infection can also be passed on during sex, so we’re encouraging anyone who is HIV positive and hasn’t been tested for Hepatitis C to ask their health practitioner for a check the next time they’re getting their routine blood tests.” 

More information on hepatitis C and HIV

• Information booklet from aidsmap.com / NAM
• Information booklet from i-Base

Reducing the risk of getting hepatitis C

People injecting drugs can protect themselves and others from hepatitis C by using drugs more safely.

Gay men’s risk of getting hepatitis C sexually seems to come from unprotected anal sex, group sex, drug use and fisting. Sharing sex toys and lubricants also appear to be risky. Using condoms for anal sex, and gloves for fisting provide protection. Information on risk reduction for gay men.

Source with reference and weblink

further material : demand screening

More Hepatitis C and HIV

posted: 22/06/2010

Hepatitis C in the UK: 2009 report is the latest update on the hep C virus from the Health Protection Agency. Figures from this yearly report show that laboratory reporting of newly diagnosed hepatitis C infections in England increased in 2008 by 6% compared to 2007, with 8,196 new cases reported in 2008.

Hepatitis C is rising among among people living with HIV, particularly gay men. Among gay men living with HIV hep C is sexually transmitted. Hep C has serious health impacts, shortens life expectancy and is harder to treat for people with HIV. Hep C treatment takes at least 6 months and has unpleasant side effects, and the success rate is much better when it is treated at an early stage. The largest number of people with and at risk of hep C howeer are injecting drug users.

Hepatitis C in the UK 2009 report and slide set
More news and information on Hepatits C and gay men living with HIV

1 in 73 Injecting Drug Users have HIV
The Health Protection Agency (HPA) has also published 'Shooting up: infections among injecting drug users in the United Kingdom 2008. An update: 2009’.

Key findings of the update include: transmission of HIV and hepatitis C infection through injecting drug use remains higher than in the late 1990s - overall, around two-fifths of injecting drug users are now infected with hepatitis C, and about one in 73 with HIV.
 
 

Hepatitis C and HIV Outlook

posted: 18/11/2009

We can now say that having both hepatitis C and HIV doesn’t make it any more likely people will go on to develop an AIDS illness, but people do have a worsened chance of dying early.

One third higher risk of early death

A massive study of all the studies, a ‘meta-analysis’ of over 100,000 people has produced these findings. Since effective HIV treatment became available in the mid 1990s, co-infected people still have a 35% higher risk of death compared to people with just HIV.

The investigators believe that that “the major contributor to mortality among co-infected subjects during the HAART [highly active antiretroviral therapy] era is likely to be liver disease.”

HIV treatments mean that many people with HIV can look forward to a long and healthy life. However, the outlook for people with both HIV and hepatitis C is significantly shorter than for people who only have HIV.

Indeed, liver-related disease is now an important cause of death in HIV/hepatitis co-infected patients. Although there is a lot of evidence showing that HIV accelerates the course of hepatitis C disease, there is less agreement about the effect of hepatitis C on HIV disease progression.

A team of US investigators therefore conducted a meta-analysis of 37 studies published before April 2008 to see what impact hepatitis C had on HIV disease progression and overall mortality.

Before HIV treatments experience
Ten of the studies were before effective antiretroviral therapy became available. These studies showed that before HIV treatment became available, people with both HIV and hep C were slightly less likely to face worsening HIV than people who only had HIV – not a worsening in HIV health as you might have expected.
This part of the analysis had 4413 people with both hep C and HIV and 10,213 individuals who only had HIV.

After HIV treatments
They then looked at studies after 1996 when modern HIV treatments became available. This part of the analysis had 25,319 people with both hep C and HIV and 61,697 people with only HIV. These showed that people with both hep C and HIV were 35% more likely to die early compared with people who only have HIV.

Older, on treatment, how long with hep C
People with both hep C and HIV who were older, or taking antiretroviral therapy had an especially higher risk of death.

Moreover, the longer someone has both hep C and HIV, then the greater the risk of earlier death.

End outcome
The results from the meta-analysis depend on whether you stop the clock when people get AIDS, or follow people until they die. If you stopped the clock at an AIDS diagnosis, then the results show there is no difference between people who only have HIV and those with hep C as well. But in life, none of us have time machines that can prevent our dying. Therefore we should pay more attention to the 36% higher risk of dying early with hep C.

Seven studies in the meta analysis looked at how hep C and HIV affected disease progression, whether this was defined as either an AIDS diagnosis or death. Co-infected people were 49% more likely to get AIDS or die early than people who only have HIV..

Liver disease likely killer
“The majority contributor to mortality among co-infected subjects during the HAART (highly active antiretroviral therapy) era is likely to be liver disease”, comment the investigators. “The meta-analysis did not demonstrate increased risks of developing AIDS-defining events among co-infected patients”, conclude the investigators.
 

What next?
They recommend that “future studies that attempt to examine mortality among coinfected subjects should attempt to determine the relative contributions of hepatitis C viremia as a surrogate marker for liver disease risk, whether injecting drug use is current…, and whether broader application of hepatitis C treatment positively impacts mortality in co-infected individuals.”

Source

Chen T-Y et al. Meta-analysis: increased mortality associated with hepatitis C in HIV-infected persons is unrelated to HIV disease progression. Clin Infect Dis 49 (10): 1605-1615, 2009.

photo credit and hepatitis c gene quilt panel 

UN Drugs - No Harm Reduction

posted: 11/03/2009

IAS, the International Aids Society and other international organisations, are insisting that countries must reject the new draft 10 year UN drug policy, because it does not include harm reduction - the supply of clean needles and syringes to prevent the spread of HIV and hepatitis. And it lacks key human rights protections.
 

Lacks critical HIV prevention points

The new UN Political Declaration on Drugs, designed to guide drug policy for the next 10 years, lacks critically important measures for treating and stemming the spread of HIV, Human Rights Watch, the International AIDS Society, and the International Harm Reduction Association said today.

The groups said that respect for human rights and HIV prevention should be at the heart of the policy, but that critical elements had been stripped from the final declaration. They called on member governments to refuse to support the declaration, which is being considered at the high-level segment of the Commission on Narcotic Drugs (CND) this week in Vienna .

Weak declaration "undermines fundamental health and human rights obligations"

"Government delegations could have used this process to take stock of what has failed in the last decade in drug-control efforts, and to craft a new international drug policy that reflects current realities and challenges," said Prof. Gerry Stimson, executive director of the International Harm Reduction Association. "Instead, they produced a declaration that is not only weak - it actually undermines fundamental health and human rights obligations."

Harm reduction services left out

What is at issue is a series of measures known collectively as "harm reduction services," which have been endorsed by UN health and drug-control agencies, including the UN Office on Drugs and Crime, UNAIDS and the World Health Organization. However the draft declaration excludes these. These measures include needle and syringe exchange and medication-assisted therapy (for example, with methadone), both inside and outside prisons, as essential to address HIV among people who use drugs. The groups noted that a wealth of evidence proves harm reduction is essential to HIV prevention for people who use drugs. The action was taken against the direct advice of UNAIDS, the Global Fund to fight AIDS, Tuberculosis and Malaria, and the UN special rapporteurs on health and on torture.

Harm reduction ommission is "unacceptable and unconscionable"

Up to 30 percent of all HIV infections outside of sub-Saharan Africa occur via unsafe injecting drug use. The groups said there is clear evidence that harm reduction interventions can halt or even reverse HIV epidemics among people who inject drugs.

"This political declaration fails public health," said Craig McClure, executive director of the International AIDS Society. "Coming less than 12 months after UN member states convened a high level meeting in New York to restate the international commitment to fight HIV, the denial of any reference in the declaration to life-saving harm reduction programs is unacceptable and unconscionable."

Human Rights failings

The political declaration also fails human rights. In country after country around the world, abusive law enforcement practices conducted under the banner of the 'war on drugs' result in extensive, and often horrific, human rights violations. In addition, overly restrictive interpretations of the international drug-control treaties at national level result in the denial of access to essential pain medications to tens of millions of people worldwide.

Both of these issues were raised by the UN special rapporteur on health and the UN special rapporteur on torture, who wrote to the CND to urge explicit support for human rights within the political declaration. All member states of the UN have ratified at least one of the core UN human rights treaties, and the UN General Assembly has consistently stated that drug enforcement must be carried out in a manner consistent with respect for human rights.

"Given the widespread human rights abuses around the world directly resulting from drug enforcement, human rights must be placed at the heart of UN drug policy," said Joseph Amon, director of Human Rights Watch's health and human rights division. "But the political declaration makes scant reference to the legal obligations of member states under international human rights treaties, nor does it insist on respect for human rights in drug policy."

Failure to be followed by Failure?

The past 10 years international drugs policy was under the banner of "a drug-free world." It's been a conspicuous failure. Continuing to exclude harm reduction from international drugs policy is not likely to reverse the failings of the past ten years. 

The international community should recognize that the current approach to international drug policy has failed, the organisations said. Concrete steps should be taken to set forth a drug policy framework incorporating evidence-based measures to address drug-related harm and the human rights obligations of states, and of the UN as an international organization, at its heart.

This means supporting harm reduction measures. It means acknowledging that punitive drug policies don't work, and have taken a serious toll on the lives and health of millions of people. It also means acknowledging that we need a new way forward.

The groups called on member states not to lend their names to a political declaration that does not sufficiently prioritise the centrality of harm reduction and human rights within the global response to drugs, and join the call from other civil society organizations for further efforts across the UN system to find a more effective, coherent, and relevant response to drugs.

The January 2009 overview document by the International Harm Reduction Association and Human Rights Watch, International Support for Harm Reduction.
 

More on Human Rights Watch's work on drug policy.