Treatment Protects Partners

posted: 13/05/2011

There’s been a lot of publicity in the last day or so about HIV treatment helping stop the spread of HIV. 96% of HIV transmissions among couples are blocked by early treatment of the partner with HIV, was the headline result from a multinational study.

The results were so striking that the study was stopped three years early and everyone with HIV who was not already on HIV treatment was immediately offered HIV treatment.

The results show that treating people living with HIV is at least as good as using condoms to prevent HIV transmission.
 

Universal access to treatment goal
This treatment for prevention success offers an extra reason for pushing the world to achieve the internationally agreed World Health Organisation goal of universal access to HIV treatment, prevention and care. The goal was to reach universal access by 2010, but better late than never. Millennium Development Goal 6 includes halting and beginning to reverse the spread of HIV/AIDS by 2015.
 

Gay men too?
The study included hardly any gay couples (only 3% were gay), so the results don’t prove a 96% reduction in transmission in gay couples. Other evidence already strongly suggests gay men living with HIV on successful treatment are also much less likely to transmit HIV, but probably not by the same amount. (Anal sex is riskier than vaginal sex for passing on HIV, gay men tend to have more partners than heterosexual couples, and other sexually transmitted infections also raise the risks).
 

What they found
The study began in 2005 of 1763 couples where one partner has HIV and the other did not (97% were heterosexual couples). They wanted to find out whether HIV treatment prevented the uninfected partner from getting HIV. It was an international study at 13 sites in Botswana, Brazil, India, Kenya, Malawi, S Africa, Thailand, USA (only one couple were from the USA), and Zimbabwe.
 

They split the couples in half randomly and half the partners with HIV immediately started HIV treatment (with CD4 counts higher than normal for starting treatment at between 350 and 550). The other half of positive partners only started treatment when their CD4 count fell to 250 or less, or they developed an AIDS defining illness.
 

• 39 (2.2%) of the negative partners out of 1763 got HIV
• Up to 11 of the 39 got HIV from someone else, not their partner in the study
• 28 (1.5%) got HIV from their partner in the study, and all but one of those were infected by positive partners who were in the delayed treatment half of the study.

That result was so stark they stopped the study and offered immediate treatment to everyone with HIV not already on treatment because the prevention effect of early treatment was so clear. Early treatment also prevented partners from getting tuberculosis (TB) with only 3 of the people treated early getting TB, compared with 17 of those treated after their CD4 count fell below 250. There were slightly more deaths among the deferred treatment group, but the difference was not statistically significant.
 

You can read the report from the US National Institute of Allergy and Infectious Diseases here  and their Q&A page about the study here
 

Aidsmap’s report

Answers in Untested Mystery

posted: 12/04/2011

HIV experts in England are puzzled why some people using STI clinics refuse HIV tests. We know for sure that some of those refusing HIV tests do have HIV (from using blood from samples given for syphilis tests and after the syphilis test is done and the blood sample is made completely anonymous, it can be tested for HIV).

The 2009 results from doing this show that 2.4% of gay and bisexual men and 0.25% of heterosexuals tested for syphilis came to the sexual health clinic with undiagnosed HIV.

But only 63% of these people agreed to a HIV test at the STI clinic - much lower than the average rate of HIV testing for people using STI clinics.

Why are so many people who have ‘undiagnosed’ HIV, refusing HIV tests?

One quarter must already know they have HIV - they are taking HIV treatment !

Some useful answers to the testing mystery have now emerged. Now we know that around a quarter of people with ‘undiagnosed’ must know they have HIV, because blood tests prove they are taking HIV treatment. These and other results, given at the British HIV Association conference in Bournemouth last week, are the first clear evidence of some answers to the ‘undiagnosed’ mystery.
 

Slightly more heterosexual women and men (32% for both men and women) than gay men (24%) are using a different clinic for STI checks than for their HIV treatment. Experts thought gay men with HIV were more likely to go elsewhere for HIV checks than heterosexuals. Experts don’t always guess right. Some people with HIV have told community organisations and patient advocates that one reason they go elsewhere for testing is to avoid unwanted, intrusive or judgemental discussion of their sexual behaviour by their own HIV clinic.
 

The results means

• 9 in 100 of the gay and bisexual men who said yes to a syphilis test but no to a HIV test have HIV. At least 2 of those 9 are on treatment but didn’t tell the STI clinic they have HIV
• 8 in 1000 of the heterosexual women and men similarly are HIV positive. At least 2 of those 8 are on treatment but did not tell the STI clinic they have HIV.
   

These findings will make little difference to national estimates of how much undiagnosed HIV there is in the country.
 

Why do gay men who don’t yet know they have HIV refuse HIV tests?
Another small study given to last weeks conference looked at why some gay men refuse HIV tests. Researchers gave an anonymous questionnaire to 19 men who didn’t want to be tested, even though they had had anal sex without condoms and have, either never been tested, or had taken anal sex risks since their last HIV test.

The men could tick more than one reason.
 

15 of the 19 men said they believed they were at low risk of HIV infection [2 of the 19 men knew their partner has HIV]

• 14 said they were emotionally unprepared for a positive result
• 4 said they don’t like giving a blood [but nonetheless gave this to have the syphilis test]
• 4 also mentioned prosecutions for HIV transmission
• 4 said they were planning to test 'next month'
• 3 mentioned worries about the confidentiality of the HIV test result.

Testing Advantages well known

Most of the men know the advantages of HIV testing

• 16 said testing could give peace of mind
• 16 said testing allows treatment to start at the best time.

Testing worries rule

But all the gay men listed the disadvantages to them of HIV testing.

• 17 said testing was stressful
• 8 were worried about having to tell a boyfriend if they were positive
• 7 were concerned about the insurance and mortgage implications.

Unready for positive result, testing stress, in denial about risks

So most of these gay men didn’t feel emotionally ready to deal with a positive result, and find HIV testing stressful.

• Most thought their HIV risk was low, despite having taken enough risks to have got HIV and needing to visit an STI clinic.

The study authors suggest investigating ways of overcoming gay men’s resistance to testing at STI clinics.
 

Source 
Reference – the free conference abstracts - read O13 & P152

Treating to Prevent HIV

posted: 03/03/2011

Could people who do not have HIV use HIV treatment drugs (PrEP) to stop themselves from getting HIV? The detailed results just out for gay and bi men are better than the early findings. This means PrEP could be approved for use in the USA by the end of the 2011.

Last year, the first results from a study of gay and bisexual men appeared. Taking PrEP cuts gay and bi men’s risk of getting HIV. But there were worries because many of the men did not take all the tablets. Some men got HIV.

HIV infection
Much better updated results were announced at the CROI conference in Boston, USA, that has just ended.

In the different places where the trial took place, including South Africa, the taking of PrEP (HIV drugs to prevent HIV infection) varied a lot.

Gay and bi men in the two USA cities (Boston and San Francisco) of the international iPrEx study of tenofovir/FTC (Truvada) had near-perfect HIV-prevention drug taking, compared with 50% tablet taking at the other sites.
 

And the men taking the greatest sexual risks for HIV, by having unprotected receptive anal sex, were taking the prevention treatment better than men taking less HIV risks – which is good to know.
 

USA approval within a year?
Lead investigator Bob Grant announced that the US Food and Drug Administration (FDA) had agreed that the trial results were good enough for the FDA to consider allowing the use of Truvada to prevent HIV. PrEP, as a result, might be approved in the USA by the end of this year.
 

First USA Guidelines for gay men published

Interim Guidance: Pre-exposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men from USA Centers for Disease Control and Prevention. 

2500 men and the results

There were almost 2500 men in this trial and 130 of them got HIV by the end. Like most drug trials men were randomly split into two groups and told they would either get Truvada, or a dummy pill, but no-one would know who was taking what, until the end. The men were therefore warned they should still use condoms, because half were using the dummy pill.
 

48 of the men who got HIV took the Truvada and 82 of the men who were taking the dummy pills, a HIV infection rate of 2.6% a year. Another 10 other men have HIV, but they already had the symptoms of HIV infection when they joined the study.
 

This means that the final ‘how well does it work’ rate in the ‘modified intent to treat’ analysis, (this leaves out the 10 men who started the study with HIV, and ignores things like different rates of tablet-taking and the men’s level of sexual risk-taking), was 42%.
 

PrEP worked better when men were over 25 (56%), among men who took more than 9 out of 10 of the tablets (68%), and among the men who were circumcised (76%).
 

Would PrEP be cost effective? 

Other new studies have now looked at the value for money of treating people to prevent HIV in South Africa. The answer is mixed. 

It is usually cheaper to treat the person with HIV than treating one or more HIV negative people with PrEP. Treating the person with HIV should reduce their viral load so it becomes undetectable and their chance of passing on HIV then becomes very small. In mixed status couples, that may be enough protection for many. But PrEP would help protect negative partners who have unsafe sex outside the main relationship and who don't use condoms.  

Source and more details

HIV in the UK

posted: 03/12/2010

The latest report on HIV in the UK has appeared from the Health Protection Agency. They found  the number of people living with HIV in the UK reached an estimated 86,500. A quarter of these people don’t know they have HIV.
 

New diagnoses among men who have sex with men stayed high (2,760); four out of five gay and bi men probably got HIV in the UK.
 

Of the people newly diagnosed in 2009, 1,130 probably acquired their infection heterosexually, within the UK, accounting for a third of heterosexuals diagnosed.
 

One in six gay and bi men, and one in sixteen heterosexuals got HIV within the previous 4-5 months before their diagnosis.
 

6,600 new people diagnosed

A total of 6,630 people were newly diagnosed as HIV-infected. This represents a fourth year-on-year decline, largely due to fewer diagnoses among people infected heterosexually abroad, mostly in Sub-Saharan Africa – there have been fewer migrants who happen to come from countries with HIV rates of HIV.
 

Older worries

Some 65,000 individuals accessed HIV care, of whom one in five were aged 50 years or over. Since 2000 there has been a three-fold increase in the number of individuals accessing care and a fourfold increase among older (greater than 50 years) individuals.

Sue Peters, regional director of the Terrence Higgins Trust in Brighton, said they are concerned at the number of older people becoming diagnosed in recent years. She pointed out that gay and bi men over 50 have lived through the worst years of HIV and men who remain HIV negative may now feel they are not going to catch it. Some men think that they do catch HIV past their 50th birthday, they are old enough for it not to cause any really serious harm.
“The same issue is with younger people who may still not be aware of the dangers of what is a life long infection. I think people sometimes feel they are immune but they aren’t and it is something that concerns us.”
 

Becoming HIV positive after the age of 50 is not recommended. The immune system becomes less able to fight serious health problems the older we get. People over 50 with HIV tend to be diagnosed late and often need to start HIV treatment immediately. Treatment for HIV becomes more complicated with older age because we often have other long-term health problems to do with being older.

Late too
Half of adults were diagnosed with HIV at a late stage of infection in 2009 (CD4 counts less than 350 within three months of diagnosis), the stage at which treatment is recommended to begin.
 

Thirty-seven English primary care trusts (PCTs) had a prevalence of diagnosed HIV greater than 2 per 1,000 population, the threshold at which expanded HIV testing should be implemented – in NW England these are Manchester, Salford and Blackpool.
 

Uptake of HIV testing was 95% in antenatal clinics and 77% among STI clinic attendees in England.
 

The quality of HIV care received is high. Based on London data, 80% of newly diagnosed patients were seen in an HIV clinic within one month of diagnosis; 90% had an undetectable viral load (less than 50) one year after starting therapy; and 93% of those in care for more than a year had a CD4 count above 200.
 

• HPA recommendations
  
• High proportions of recently acquired HIV infections among newly diagnosed gay and bi men of all age groups underscores the need for ongoing prevention efforts tailored to all ages in this group.
• The national recommendation of universal testing for all attendees of STI clinics should be audited and improved in many clinics; the existing national standard for HIV testing in STI clinics should be reviewed so as to encourage better performance.
• In high prevalence areas (greater than 2 per 1,000 people diagnosed HIV infection) the routine offer and recommendation to accept an HIV test for all adult general practice registrants and general medical admissions should be widely implemented given the recently reported success of pilot projects. The upper age limit for application of this policy should be set with regard to local circumstances.
• Roll-out of clinical outcome indicators to assess the quality of HIV care received by patients, already in place in London, should be extended to the rest of the country.

Sources

Health Protection Agency - HIV in the UK 2010, report and PowerPoint slides

Aidsmap 
 

Brighton Argus

PinkNews

Swiss Statement Impact

posted: 09/11/2010

The “Swiss Statement,” nearly three years ago, from leading HIV clinicians said that effective HIV treatment is, subject to conditions, enough to stop HIV transmission. There is now considerable evidence from a large Swiss study that while condom use has fallen, HIV infections there have not risen. This is despite the proportion of people reporting sex without a condom with their main partner increasing after the statement.
 

People believe treatment prevents transmission
“In contrast to earlier results from our cohort, …. we now observed an association of a suppressive ART [antiretroviral therapy] and unprotected sexual contacts in MSM [men who have sex with men] and heterosexual women with stable partners, indicating that some groups with HIV infection have adopted the belief that treatment of HIV infection is a sufficient HIV-prevention measure”, write the investigators.
 

Editorial alarm
An editorial in the same issue of Clinical Infectious Diseases sounds an alarm about individuals making decisions about the use of condoms based on having an undetectable viral load. The editorial points out that some HIV transmissions are thought to be from people with an undetectable viral load, and that we don’t know everything about how treatment affects infectiousness.
 

It is equally true to point out, as George House Trust does here, that people who reliably use condoms sometimes also pass on HIV. Condom accidents happen; treatment accidents happen too. And we still don’t know everything about condom use and HIV transmission either. People have the right to choose the sexual risks they take.
 

Swiss Statement
In January 2008 a group of senior HIV doctors in Switzerland published what has become known as the Swiss Statement.
This said that HIV-positive heterosexuals could stop using condoms with their regular HIV-negative partner if:

• their partner agreed
• they were taking HIV treatment
• their blood viral load had been undetectable for at least six months
• they did not have any other sexually transmitted infections.

Controversy surrounded the Swiss Statement. The Swiss Statement was followed by similar statements from French, German and USA HIV clinicians. There is a general consensus that taking HIV treatment substantially reduces the risk of sexual transmission of HIV. Nevertheless, experts believe that there remains a low risk of HIV transmission and advise the use of condoms alongside HIV treatment.

Condom use changes

The Swiss investigators wanted to see whether condom and other behaviour has changed following the statement. They analysed the self-reported condom use of 7309 patients between 2007 and 2009. They split the people into the main HIV risk groups: gay and other men who have sex with men; heterosexual men and women; and injecting drug users.
Other recent Swiss research has shown that about a quarter of gay men are using unreliable HIV risk reduction strategies such as sero-sorting (choosing partners with the same HIV status) or strategic positioning (being insertive in sex rather than receptive). They note that these methods have never been promoted in Switzerland.
 

Four out of five are undetectable
A total of 80% of patients were taking HIV treatment, and 82% of these individuals had an undetectable viral load.
 

One partner people
Most people reported sex with a single partner - 46% of gay men, 80% of heterosexual men, 91% of heterosexual women, and 75% of injecting drug users have one partner.
 

More than one
18% of gay men, 4% of heterosexual men, 1% of heterosexual women and 3% of injecting drug users said they have both regular and casual partners.
 

37% of gay men said they only had casual partners, as did 17% of heterosexual men, 8% of heterosexual women and 22% of injecting drug users.
 

Condoms
Regular condom use was reported by 89% of individuals with a regular HIV-negative partner and by 48% of those whose partner was also HIV-positive. For all four HIV risk groups (gay men, heterosexual women, etc) , rates of steady condom use were lower with regular partners than casual partners (88% vs. 92%). In other words, people were more likely to use condoms to protect casual partners than a main partner.
 

Sex without condoms rose:

• the longer the time since the Swiss Statement
• when people have an undetectable viral load (gay men, and heterosexual women with stable partners)
• among younger people
• with moderate to severe alcohol use (heterosexual women, and injecting drug users with stable partners, and heterosexual men with casual partners)
• with illicit drug use (gay men, and heterosexual women with stable partners, and gay men, and heterosexual men and women with casual partners).

Swiss Statement effect with regular partners
The investigators focused on reported condom use with regular partners. They found that even before the Swiss Statement, the proportion of gay men and heterosexual women reporting unprotected sex with stable partners was already rising. After the statement appeared, condom use fell further among people who have an undetectable viral load.
 

Gay men, heterosexual men and women whose viral load was undetectable were all significantly more likely to have unprotected sex with their main partner after the statement.
 

“The effect of the ‘Swiss Statement’ was most pronounced in groups with stable partners who had an undetectable viral load”, comment the investigators. This is not surprising. The Swiss Statement was a precise and targeted message intended for heterosexual people in stable relationships. The researchers say that people were able to accept the “complex recommendations” of the statement.
 

No rise in infections
The investigators note that the statement and these changes in sexual behaviour have not increased new HIV infections in Switzerland.
 

They conclude that “because ART influences sexual behaviour …., adherence to treatment and plasma viral load should be regularly monitored …., and counselling of couples should be advocated.
Such counselling should be individualised, and account should be taken of drug and alcohol use.
 

Editorial angst
Dr Myron Cohen, author of the editorial, says that there is “every reason to pause and reflect” about the actual impact of HIV treatment on infectiousness. “The protection provided from ART is not absolute and is not absolutely predictable”, he writes.
Cohen notes that there are many unanswered questions about the infectiousness of people taking suppressive HIV treatment. These include the risk of transmission over time; the impact of different HIV treatment combinations on infectiousness; and the risks involved with anal and vaginal sex.
 

The editorial worries about HIV transmissions, as HIV clinicians usually do. People using condoms also sometimes accidentally pass on HIV. There will never be absolute guarantees in HIV prevention. Condom accidents happen; treatment accidents happen too. People have the right to choose the sexual risks they take.

The evidence here is that Swiss women and men, gay and straight, are being sensible. There has been no reported rise in Swiss HIV infections despite less use of condoms and greater reliance on treatment for prevention. Dr Cohen should relax.
 

Source 

Source with references