USA Prevention Treatment Gay Guidelines

posted: 08/02/2011

The first guidelines for HIV negative gay and bisexual men wanting to reduce the risk of getting HIV by using the anti-HIV drug Truvada have appeared.

Taking HIV treatment drug(s) before sex is called pre-exposure prophylaxis (PrEP) and it is not guaranteed to work.

Just two months after the first positive results showed that Truvada can sometimes help, this ‘interim guidance’ has very quickly appeared.
 

The USA public health body, the Centers for Disease Control (CDC), were worried that unofficial, poor use of Truvada and bad habits would grow up if they didn’t put out some guidelines quickly.
 

Prescriptions with detailed support
In the guidelines prescriptions should only be given for 90 days at a time, with HIV testing, adherence counselling, sexually transmitted infection check-ups, sexual risk counselling and condoms provided before new prescriptions are issued.
 

Only if HIV risk ‘substantial’ and continuing
The guidelines state that PrEP should only be provided for men who have sex with men, specifically those who are “at substantial, ongoing, high risk for acquiring HIV infection”.
Pre-exposure prophylaxis involves HIV-negative people taking antiretroviral medications in order to reduce their risk of acquiring HIV. In November, a study conducted with gay and bisexual men in six countries showed that daily use of the two drugs tenofovir and FTC (combined in one pill as Truvada) reduced the risk of infection by 44%.
 

However many of the gay and bisexual men participating in the trial did not take the pills each day, as prescribed. In men who did take the drugs consistently, results seemed to be much better. In men with very poor adherence, results were worse.

However extensive analysis of the adherence data from the trial has not yet been completed, nor have the trial results been replicated in other settings.
 

The CDC only supports using Truvada when it is used almost exactly like it was in the trial. That is why they are limiting its use now gay and bisexual men at high risk of getting HIV.
 

Truvada indicators
The guidance gives quite a broad indication of which men PrEP may be suitable for, citing only lack of condom use in combination with “frequent partner change or concurrent partners in a geographic setting with high HIV prevalence” as examples.
 

Truvada only
The CDC says that antiretrovirals other than Truvada should not be used for PrEP and that the same daily dosing schedule that was employed in the trial must be followed. Therefore, ‘intermittent’ dosing (i.e., before or after sex) is not endorsed.
 

Adherence and continuing prevention support
Moreover adherence support must be a “routine component of any PrEP program”. It should be provided before PrEP is issued, and then at least every 90 days.
 

Similarly, PrEP should only be delivered “as part of a comprehensive set of prevention services” that includes risk-reduction counselling, ready access to condoms and the diagnosis and treatment of sexually transmitted infections. These activities should take place each 90 days, before a new prescription is issued.
 

HIV test first
Before PrEP is provided, clinicians must also check that the patient is HIV-negative. If he has any signs or symptoms that may be linked to HIV seroconversion, RNA testing is recommended. He must also be screened for sexually transmitted infections and hepatitis B, and have his kidney function assessed (Truvada can sometimes harm the kidneys).
 

Other tests for side-effects are required after three months and then annually. Any serious adverse events should be reported to the Food & Drug Administration (FDA).
Cost will be a central concern. In the USA medical insurance companies are unlikely to pay for this prevention use of Truvada but if men have the cash USA doctors can prescribe it. A month’s supply costs around $1000, and USA patients would also have to pay for counselling, side-effects monitoring and doctors appointments.
 

Source

Smith DK et al. Interim Guidance: Pre-exposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men. Morbidity and Mortality Weekly Report 60: 65-68, 2010.

 

Oral Sex and HIV

posted: 10/09/2010

The gay men’s sex survey sometimes tells us surprising things, but the news that almost all gay and bisexual men have oral sex - 99% - was no surprise at all. With HIV, what do men need to know?
 

What about HIV?
How risky is oral sex for men with HIV? How risky is it for positive men’s partners?

There’s a lot of confusion about this – at all our newly diagnosed courses this causes big discussions and lots of questions.
 

Doctors and researchers aren't sure exactly how many people get HIV from oral sex. Some think hardly anybody ever gets HIV from oral sex, but others think 3 out of every 100 HIV+ people got HIV through oral sex. A review of all the oral sex studies in late 2008 worked out that the risk of getting from oral sex was very low, but the risk isn't zero.

Whatever the oral sex risk, it is always much safer than anal or vaginal sex without a condom.
 

How risky is oral sex?
The likelihood that HIV is passed on from an HIV-positive person to an HIV-negative person during oral sex depends on

• whether a man with HIV sucks, or gets sucked
• the viral load of the man with HIV 
• the dental health of the man sucking
• if the man sucking has a sore mouth, or throat, oral cuts, sores or abrasions 
• if either man has a Sexually Transmitted Infection (STI).

Having a high viral load in the blood usually means that the viral load is also high in the semen, and that makes HIV easier to pass on during sex. Although having an undetectable viral load in the blood usually means there is an undetectable viral load in the semen, this isn't always true. And untreated sexually transmitted infections (including infections without symptoms), cause viral load in semen to increase.

But all in all, if you have an undetectable viral load, the chances of passing on HIV are very low in oral sex.
 

Oral sex is never risk free. It’s also easy to pass on and get some other sexually transmitted infections, such as syphilis, herpes and gonorrhoea.

Oral studies
A number of studies looked at the risks of HIV transmission from oral sex.

• One American study reported that of 122 gay men with HIV, 8% reported oral sex as their only risk activity. But this study is not really trusted. It is based on very few men and some of the men who first of all said oral sex was the only risk they took later on admitted they had anal sex without condoms.
• Another study of over 100 couples didn’t find any cases of oral transmission of HIV over a ten year period, where one partner was HIV-positive and the other HIV-negative.
• Another study from the USA found the risk to be effectively zero, but didn't exclude the possibility of there being a risk.
• Other researchers in 2008 pooled the results from all the oral studies and found that the risk was very low, but not zero.
   

We are unlikely to ever have an exact answer: the best we can say is low risk, but not no risk.
 

When is oral sex more risky?
It is important to put oral sex HIV transmission risks in perspective.

If you and your partners are having anal sex without condoms, first do something about reducing your anal sex risks, because the risks of HIV transmission during anal sex are so very much higher than in oral sex. Using condoms during anal sex will make far more difference in reducing the risk of passing on HIV, than trying to reduce the already small risk from oral sex.
 

Think of oral sex like being a safe car driver – an accident is always possible, but unlikely.

Think of anal sex like speeding and drink driving – an accident is quite likely. To reduce the chance of passing on (or getting HIV), using condoms makes sense, like it makes sense to stop drink driving and speeding. Using condoms reliably during anal sex is what we should really try to do better.
 

How can you reduce oral risks?
If you do want to cut the HIV risks during oral sex, there are several ways. Some of these are more acceptable than others, so make your own risk decisions. Many of these steps will also cut the risk of other sexually transmitted infections:

• You may decide the risks with oral sex are low enough to carry on as before
• You may prefer not to have oral sex because you do not want to take even a tiny risk
• You may decide to have oral sex with fewer men at a time, and in total
• You may decide to have oral sex using a condom
• Men with HIV may decide only to suck, as this is far less likely to pass on HIV than sucking
• Men who don't have HIV may decide only to be sucked, as being sucked by a positive man is far less likely to pass on HIV 
• Men with HIV may decide not to cum in a partner’s mouth. There is a theoretical risk of getting another HIV strain, or drug resistant HIV, if you let another man with HIV come in your mouth. 
• You may decide to have less vigorous oral sex, and not to deep throat
• HIV negative men should look after their teeth and mouths. The risk of HIV transmission increases if a HIV negative man sucking has bleeding gums, ulcers, cuts or sores in his mouth. He should not brush his teeth or floss before sucking, because that makes the gums more open to HIV
• Get regular sexual health checks. Sexually transmitted infections raise the risk of passing on HIV to a negative partner. For HIV negative men, sexually transmitted infections raise the risk of getting HIV.

Source 1

Source 2

HIV Caring

posted: 17/05/2010

LGF are launching support for lgbt people who are caring for others, including partners and friends with HIV. As part of the service you will be able to go online and find information to help you as an LGBT carer, keep up to date with relevant news and events, and interact with other carers who understand how you feel.

Online support

You will also be able to find useful links to services in your area that are LGBT friendly and there to support you. This online service will be completely safe and confidential for everyone. Take a look at LGF's new Carers webpages, when this is launched at the end of this month.  

Meeting others
For some carers, physically meeting others face-to-face is a good way of getting the information and support that you need. So there will be a support group launched in Manchester on Wednesday 16th June from 5.30pm – 7.30pm, for carers to come along to – either as a one-off drop in to pick up information, or for more regular support. This group will understand your needs as an LGBT carer and can be your first step into other LGBT friendly services to support you. The support group will meet at The Lesbian and Gay Foundation, 105-107 Princess Street, Manchester

More information
contact Glenn Street on 0161 234 4254. He’s part of Manchester Council’s Carers team.

Support group launch 5.30-7.30PM Wednesday 16th June
@ The Lesbian and Gay Foundation, 105-107 Princess Street, Manchester
After this launch event the regular carers support group meetings will take place on the last Monday of each month.

A new lgbt carers website will be launched at the end of May and this will include the online forum

The website and forum will offer information, links to local services, news and events listings, and a place for LGBT carers to interact with others who understand how they feel. This online service will be completely safe and confidential.
 

Making It Count - Gay HIV Consultation

posted: 19/04/2010

The latest version of the gay / bi men’s HIV prevention and sexual health strategy for England, Making It Count, is now open for your comments. Making it Count, is rewritten and fully updated from the third version, which appeared in 2003.

Making it Count is the planning framework for CHAPS, the multi-agency partnership for HIV prevention and education of gay and bisexual men in England.

The latest edition picks out the key choices facing men who have sex with men that affect HIV transmission rates, and pays attention to what helps motivate men.

It’s designed to bring together education and empowerment, with the values and social norms that will promote the best sex with the least harm among gay men and bisexual men.

This draft doesn’t have the final stamp of approval from the CHAPS partners, but there is broad agreement. They want your views first.

Some of the questions to think about are :

• How well does it meet the sexual health and onward HIV transmission needs of gay / bi men diagnosed with HIV?
• Is positive prevention given enough priority?
• Are men diagnosed with HIV involved enough in positive prevention?

Making It Count 2010 – draft     pdf 840KB

or by direct download from Sigma Research

Deadline for comments      09.00am, Monday 14 June 2010.

Making comments

• phone 020-7820 8022 and speak to Ford Hickson
• email Ford, either with comments made on the pdf or in an email message
• post to Sigma Research, 77a Tradescant Road, London, SW8 1XJ, writing your comments on a paper copy.

Positive Men’s Sex Rights

posted: 09/03/2010

Calls to improve the sexual health of gay and bisexual men living with HIV across England were made at the national gay men’s sexual health conference that has just ended in Sheffield. George House Trust put up a strong case for improving the sexual health support provided for all men living with HIV.
 

Top experts
The conference heard from four George House Trust experts, including young gay Positive Speaker Craig, who came out about having HIV to thousands at the Manchester Pride Candlelit Vigil. In five out of the six conference sessions, our experts led the way. The conference heard that meeting the sexual health needs of gay and bisexual men living with HIV is critical, about positive prevention (involving positive men in reducing onward HIV transmission), calls for widespread campaigns to stop HIV stigma among gay men, and for the greater use of positive speakers to challenge stigma and empower men living with HIV.
 

And positive men too
We’ve been campaigning about these for years. Our efforts are paying off, but improving things across the whole country is slow because we can only persuade and encourage other organisations to do the right thing. At last, CHAPS has now added supporting men living with HIV to the national strategy for gay and bisexual men’s HIV prevention.
 

Status check
With LGF, who are part of CHAPS, we produced our Update Your Status campaign encouraging undiagnosed gay and bisexual men to test regularly for HIV. Testing and diagnosis helps improve the sexual health of men who do turn out to have HIV and cuts the number of gay men diagnosed with HIV too late for the men to get the best out of their HIV treatment.
 

Positive prevention pioneers
In the next couple of months we will hold an national symposium in Manchester for experts in Positive Prevention with gay and bisexual men with HIV. This will start work on the first national CHAPS programme for gay men’s positive prevention.
 

Positive prevention was neglected because the national strategy aimed instead at undiagnosed men. This left out the many positive men who are passionate about reducing HIV transmission. George House Trust wants men with HIV involved in developing the resources, knowledge and skills to maximize sexual health and cut HIV transmission.
 

Work in some countries on positive prevention is well ahead of the UK – for instance Canada already has its national Poz Prevention strategy and has produced a booklet for HIV+ gay men and Ireland has its own booklet.
 

Face to face and working behind the scenes
Most of George House Trust’s efforts directly support people living with HIV. What is not so well known is our important behind the scenes work. This backstage work aims to cut the number of people becoming HIV positive and working for better services to meet the changing needs of people living with HIV across the country. It’s not so glamorous and it often takes time to show results, but work like this is essential to prevent even more gay and bisexual men from needing services in the first place, as well as improving the lives of men who do have HIV.
 

Our behind the scenes work is a form of long term indirect prevention - taking steps to stop even more people becoming HIV positive. Everyone who gets HIV potentially requires a life time of support from services such as ours.