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

HIV and Teenage Pregnancies

posted: 26/01/2011

Behind the good news that 58 London teenagers with HIV successfully gave birth to 66 babies, there’s another story.

This is a saga of sex education that isn’t working, major gaps in HIV prevention, little or no use of contraception, unplanned pregnancies, vulnerable teenagers and sexual abuse, domestic violence, undiagnosed HIV, late diagnosis, further pregnancies after the birth, and complex psycho-social problems. 
 

We learn this from the first British study to look at pregnant teenagers with HIV, in the latest issue of the British HIV Association journal, HIV Medicine.

Over the seven years up to 2007, 12 London hospitals found 58 teenage (13 – 19) women with HIV who became pregnant. 66 babies were born live to the 58 mothers and only one baby developed HIV. The mothers (and the babies) have done well and that is what the study was looking into.
 

Gaps and needs

But the study uncovered evidence of significant gaps, and exposed teenagers’ needs and some of the life problems that can help explain these pregnancies, and how HIV pregnancies and HIV transmissions to vulnerable teenagers might be avoided.
 

The young women here faced “difficult medical and social circumstances,” used condoms infrequently, and a quarter became pregnant again within one year. Other studies have shown many young people with HIV have complex psychosocial problems, take high levels of sexual risk and have significant recreational drug and alcohol use. This study found this too.
 

11% of the new HIV diagnoses in the UK are young people aged 16 to 24.

Ethnicity
Four out of five pregnant teenagers have ethnic minority backgrounds:

• Black African, 59%
• Black Caribbean, 17%
• Other ethnicities 10%
• Only 14% were white females.

Almost three quarters (72%) were born abroad.
 

When infected?

One woman was definitely HIV-positive from birth, but as many as 43% of the women might have got HIV as babies from their mothers. These young women were diagnosed with HIV in their teens, but after they begun their sexual lives, so we don't know how they became HIV positive. 
 

Late diagnosis too

Some of the young women were diagnosed at a late stage of HIV : 5% of the young women had already developed symptoms of HIV illness, and 9% had an AIDS-defining condition.

However, most of the women (87%) had no HIV symptoms.
 

Almost two-thirds of the young women (63%) were diagnosed with HIV during the normal antenatal checks, and the others were diagnosed before they became pregnant.
 

How infected?
How might these young women have got HIV?

• 1 (but possibly 25) infected from mother to baby 
• 42 (63%) migrated from a high-HIV-prevalence country (so possibly mother to baby, possibly sexual, possibly through infected blood or tissue)
• 24 (36%) sexually through a ‘high-risk’ partner, or someone with HIV

Most (92%) were sufficiently sexually active before they became pregnant to have had a sexual health screen the year before, and 45% have had another sexually transmitted infection.

No condoms or contraception
Most of the pregnancies (82%) were unplanned, and only four were taking anti-HIV treatments when they conceived.

• Only 1 in 3 used condoms, and often condom use was inconsistent 
• 2 out of 3 didn’t use any contraception.

2nd pregnancies

Despite this, the hospital notes show that less than half (43%) of the new mums were advised about contraception after they had their baby, and not surprisingly 1 in 4 of the women then had a second pregnancy within a year. Contraception advice (and having a baby as a positive teenager) is not enough to prevent conception again. 47% of the second pregnancies followed contraception advice, 88% of the second pregnancies were unplanned and 12% ended with a termination.
 

Life problems
“Significant and complex psychosocial problems” were very common, for example 

• Almost half (45%) were sexually abused
• 58% had housing problems
• 63% had financial problems : only 8% were in paid work, the rest were unemployed (54%) or students (38%).

94% took anti-HIV treatment during pregnancy and for most (81%) this was to prevent mother-to-child transmission of HIV. By the time of the birth 62% of women had an undetectable viral load.
 

Good results for mums and babies

The investigators emphasise that despite their vulnerability and difficult social and medical circumstances, these HIV-positive teenagers had a “favourable” result – they did well themselves and their babies are fine.
 

The authors say the good results were due to the “multidisciplinary care the patients received.” This was provided by expert teams working closely together at major London hospitals - HIV physicians, obstetricians, paediatricians and specialist midwifes.
 

They say their study identifies “a need for more effective strategies in the management of HIV-infected teenagers with particular emphasis on sexual and reproductive health.” To meet these needs, the authors call for the establishment of “a one-stop shop including HIV care, sexual and reproductive health input and psychosocial support in an appropriate environment provided by skilled staff in a sensitive and nonjudgmental manner.”
 

UK Guidance Managing the sexual and reproductive health of teenagers with HIV

Acute HIV prevention needs of vulnerable teenagers

While this study says nothing about HIV prevention needs, (they were studying how well the the care for HIV positive pregnant teenagers and babies worked), it is very plain that these pregnancies, and teenagers becoming HIV positive exposes a major failure to meet HIV prevention needs.

At least a third of these teenage women were sexually infected with HIV. 

Almost all of these teenagers were sexually active in the year before they became pregnant, when they may not yet have got HIV. 92% of them had a sexual health screen in the year before they became pregnant. Almost half have had an STI.

Four out of five have an ethnic minority background; three quarters were born abroad and are migrants.

Most have complex psycho-social needs and are likely to be in contact with other services.

Target vulnerable teens for intensive HIV prevention

All services providing sexual health checks and contraception services to teenage women matching this profile should particularly target HIV information and support services to meet those needs.

The teenagers' male partners are invisible in this study - some must have HIV. There is a risk that those males without HIV might get HIV from their girlfriends, because few of the males are using condoms consistently.

We know nothing about their male partners' ages, ethnicities, whether they are migrants, use of sexual health services, or whether they are also vulnerable because of complex psycho-social problems. We need more information before we can meet the male partners' HIV and contraception support needs.       

Source, with reference

Related news - Unplanned pregnancies in teenagers infected from their mothers

Rise in Over 50s HIV Infections

posted: 21/07/2010

People over 50 are as much at risk from unsafe sex as younger people, the UK’s Health Protection Agency (HPA) has just warned. Today it revealed evidence, at the International AIDS Conference in Vienna, that the number of people over 50 who are catching HIV has more than doubled in seven years.
 

In 2000 there were just 299 new HIV infections among the over-50s, according to the HPA. But in 2007 there were 710 people infected.
 

Gay and bi men are the majority infected when older, but white heterosexual men infected abroad - typically in Thailand - are another significant group of older men who are diagnosed.

Late diagnosis common
Half of those diagnosed when over 50 were diagnosed late. Younger people are much less likely to be diagnosed late. Late diagnosis is bad news when you are older - during the eight year study period three quarters of the deaths among people aged 50 and over occurred within one year of the diagnosis, with half of those diagnosed late. Unfortunately, late diagnosis with HIV reduces people's life expectancy and quality of life. If treatment is started late it cannot undo all the unnoticed damage already caused by HIV.

Some people diagnosed after 50 were infected when they were younger. After some early symptoms (such as flu-like symptoms with a rash), many people after HIV infection remain apparently fit, healthy and continue to feel well, without suspecting they have HIV, for as long as 10 years.

Most are recently infected by risky sex
But half of the over-50s diagnosed had recently been infected, through taking chances without condoms.

Getting away with risks in your earlier years doesn't mean that luck will continue.

Letting down your guard just because you are older can still catch anyone out. We often hear older people say, rather sheepishly, 'I should have known better'.
 

Keep on testing - and condoms
"This highlights the importance of HIV testing, whatever your age," said Ruth Smith, a senior HIV scientist at the HPA's Centre for Infections. "We must continually reinforce the safe sex message – using a condom with all new or casual partners is the surest way to ensure people do not become infected with a serious sexually transmitted infection such as HIV."
 

Her co-author, Dr Valerie Delpech, head of HIV surveillance at the HPA, said people in the older age group needed to be aware that they were just as much at risk as young people if they had unsafe sex.
 

"Although adults aged 50 and over account for just 8% of all new HIV diagnoses, the fact that cases have more than doubled in recent years serves as a timely reminder that anybody is at risk of HIV infection if they do not use protection and practise safe sex," she said.
 

More information from HPA

Source
 

Teens' Unplanned Pregnancies

posted: 04/05/2010

Around one in seven adolescent females with HIV became pregnant, according to a recent check at UK HIV clinics. Most of the pregnancies were unplanned and a quarter were ended. Although there were problems with adherence to HIV treatments medication among many of the young women, none of the women transmitted HIV to their baby.

These pregnancies highlight the need for sexual health education for young people who acquired HIV from mother-to-child transmission in the 1980s and 1990s. To help health professionals with this work, the HIV in Young People Network (HYPNET) and the Children’s HIV Association (CHIVA) have just produced a draft guide for managing the sexual and reproductive health of HIV+ adolescents.

19 clinics responded to a survey of all mother-to-baby infected young women aged twelve or over. There were 172 young women, and 27 young women had a total of 36 pregnancies.

Of the 36 pregnancies:

• 75% were unplanned
• 86% involved regular partners
• 39% of partners were not aware of the woman’s HIV status
• 25% of the pregnancies were terminated
• 14% ended in miscarriage
• 50% resulted in a live birth and
• 11% were still pregnant at the time of the report.

Most mothers had detectable HIV

Of the 18 live births, 89% of the mothers were on combination therapy at the time of delivery.
In only 8 (44%) of the live births did the mother have an undetectable viral load of <50 copies/ml before delivery. 80% of mothers had poor adherence to treatment during pregnancy, with two being given Directly Observed Therapy (DOT).

One third of the babies were premature and five required neonatal intensive care. Three had a low birth weight. No congenital anomalies were reported. No cases of HIV transmission were recorded.

Two-thirds of the young mothers were reported as having complex social needs, with one quarter of their babies requiring foster care.

Draft guidelines

The first ever guidance for managing the sexual and reproductive health of HIV-positive adolescents has been produced. The document makes it clear that, even if the issue is not raised by the young person, then paediatricians should take responsibility for covering sexual health education and needs during consultations, with the process starting well before sexual maturity is reached. The guidance states that HIV-positive adolescents require the same sexual health information as their HIV-negative peers, as well as further help on applying it while living with HIV.

Topics which need to be discussed include preventing the transmission of HIV and other sexually transmitted infections; contraception; symptoms and treatment of sexually transmitted infections; vaccinations; HIV disclosure; post-exposure prophylaxis; conception options and fertility issues; pregnancy and avoiding mother-to-child transmission; options if there is an unplanned pregnancy; sexual exploitation and sexual violence; sexual difficulties; psychological support for negotiating safe sex, self-assertion, bullying or other issues.

How to work with young people with HIV

The guidance explores some of the issue involved in delivering sexual health work with this age group. Sexual health services for young people should be confidential (without disclosure to a parent or guardian), provided that the young person is assessed as being ‘Gillick competent’ (has the maturity to make their own decisions and to understand the implications of them). For under 16s, Gillick competence needs to be assessed at each clinical visit as it can change over time.

The guidance notes that adolescents value consultations that are non-judgemental, give them correct information and which maintain confidentiality. Professionals are encouraged to use simple language, check understanding and not overload adolescents with too much information. They should not make assumptions about whether the young person is sexually active or what their sexuality is.

The draft guidance is open for comments and feedback until May 28.

Source with references

Cheaper Female Condoms

posted: 17/04/2009

A cheaper, more user-friendly female condom could have a vastly bigger impact in the global fight against HIV. Female condoms are important - at present they are the only woman-controlled means of protection against HIV. The first female condom was introduced in 1993.

Yet despite promotion by the United Nations and others, female condom use is still tiny, although women are more likely to become heterosexually infected than men.

The USA's Food and Drug Administration approved FC2, a new version of the female condom produced by the Chicago-based Female Health Co.

About 35 million female condoms were distributed worldwide last year, but that compares to more than 10 billion male condoms, which are far cheaper, familiar and a bit easier to use. However, many men refuse to use condoms, putting women at risk.

Made from cheaper material

Though the new female condom looks like the one we already have - a soft, transparent sheath with flexible inner and outer rings - the FC2 is made from synthetic rubber rather than polyurethane, making it cheaper to produce.

Quiet to use

Mary Ann Leeper, of Female Health Co. said the FC2 also is less noisy during use. People complained the original squeaked during use, which is embarrassing.

The developing world price for the current female condom is about $1 each and the cost of the FC2 is one-third less, and may fall if production rises, enabling health organizations to distribute many millions more than at present.

For now, the price will be about US$0.60c (mass-distributed male condoms cost very much less, $0.06c each. This price difference is still huge and a major issue in the developing world. If your income is $1 a day you are not able to buy these, but might conceivably manage to buy male condoms at 4 cents. However if demand rises FC2 production costs should fall and the price halve to about 25 cents.

The Female Health Co. distributed 14 million of the new FC2s last year along with 21 million of the original. The FDA announcement was welcomed by HIV prevention advocates because it means the U.S. Agency for International Development (USAID), one of the largest global providers of condoms, can now distribute them.

"If presented in the right way, many women do like it," Hoffman said. "To find these people and help them and train them, you need systematic programming, which costs money."

Resistance is less of a problem in some developing nations. The U.N. Population Fund, government agencies and nonprofits are aggressively promoting female condoms in places such as Brazil, Ghana, Zimbabwe and South Africa.

Zimbabwean and Ghanaian Women's Demands

Women's groups in Zimbabwe collected more than 30,000 signatures demanding access to the female condom. In Ghana, nonprofits say more than 10,000 people have attended training programs that teach women how to insert female condoms — they require careful instruction to be used properly — and how to negotiate with their male partners.

"The mindset is changing, but there are still a lot of challenges," said Bidia Deperthes, the Population Fund's HIV technical adviser for condoms. "Accessibility is still minimal. There's a huge demand, and we're not meeting it."

50 million target

Deperthes hopes that with FDA approval of the FC2, the number of female condoms distributed globally could climb to 50 million this year. If the numbers keep rising, she said, the cost to public-sector distributors for each FC2 could drop as low as 25 cents.

Women friendly

Another challenge is a stigma associated with the female condom in some places because prostitutes are among those deemed to benefit most from using it. On the other hand, advocates of the female condom say it has invaluable safe-sex potential for married women whose husbands are unfaithful and shun male condoms.

Serra Sippel, executive director of the Center for Health and Gender Equity in Washington, said FDA approval of the FC2 is a key step toward "putting the power of prevention in women's hands." But she bemoaned the product's limited over-the-counter availability.

"We'd love to see the profile raised, to have commercials about it and normalize it so people aren't embarrassed," she said.

The female condom's advocates stress that it will never be the "magic bullet" that by itself turns the tide in fighting AIDS. But, they say, it should be a bigger part of the arsenal.

"It's not going to be the one answer," Hoffman said. "But it's got a lot more to contribute than it has to date."

Other women's prevention

Efforts are being made to develope vaccines and microbicides that will also put women in a far better position to protect themselves, but results are disappointing and there have been many failures so far.

Source