Over 50s HIV Infections Double

posted: 18/08/2010

New HIV infections among people over 50 have doubled in England, Wales and Northern Ireland in the last seven years, and almost half the over 50s were diagnosed late, according to a new study in the latest issue of AIDS.
 

More and more HIV experts are now thinking hard about older people with HIV. Not only are the numbers of older people with HIV rising steeply, older people are also getting HIV, health prospects are worse when you are over 50, and it is clear that there are some different problems in living with HIV when older.
 

This latest study looked at older people with HIV in England, Wales and Northern Ireland between 2000 and 2007. The starting point for ‘older’ is age 50 or over.
 

While the numbers of over 50s with HIV tripled between 2000 and 2007, there was also a sharp rise in the number of older adults getting HIV. Is the tripling of the number of people with HIV over 50 because people are living longer because of HIV treatments, or is it because more people are getting HIV after 50?

To find out the Health Protection Agency decided to analyse the national HIV data for the time between 2000 and 2007.
 

Nearly 1 in 10 new infections among people over 50
They found 8% of all new HIV diagnosis were among people over 50. But the new infection rate among over 50s is still rising and in 2007 it reached 9%. The number of older people who were newly diagnosed more than doubled, from 299 in 2000, to 710 in 2010. Almost three-quarters of these new diagnoses were people aged between 50 and 59.
 

Gay and other men who have sex with men were 40% of all the people diagnosed over 50. A third of the newly diagnosed were heterosexual men, and 25% heterosexual women.
Almost all (94%) the gay men are of white backgrounds. Older heterosexual men and women were rather more likely to be white than heterosexual men and women under 50.
 

8000 and rising
A total of 8255 older adults used HIV clinics between 2000 and 2007. This is 16% of all the people using HIV clinics.
 

Late diagnosis and AIDS
20% of the older adults developed an AIDS defining condition in the years 2000 - 2007. Mostly (91%) an AIDS condition was diagnosed within three months of diagnosis with HIV – this means HIV was diagnosed at a really late stage. This is twice the rate of AIDS diagnoses found among the under 50s.
The Health Protection Agency definition of late HIV diagnosis is when the CD4 count is below 200 at diagnosis. People diagnosed over 50 are significantly more likely to have a CD4 count this low than the under 50s (48% for over 50s, 33% for under 50s).

HIV treatment is now started normally when the CD4 count is around 350, so really many more people were diagnosed late than these HPA figures suggest. By the time the CD4 has fallen to 200 avoidable health harm has already been done.

More deaths, sooner
538 (13%) of the people over 50 died between 2000 and 2007. People diagnosed with a CD4 below 200 were 14 times more likely to die than younger patients with this CD4 count (14% for the over 50s, 1% for the under 50s).
 

Moreover, over 50s who are diagnosed late were approximately two and a half times more likely to die within a year of their diagnosis than under 50s with a CD4 count below 200.
 

The overall mortality rate amongst older patients was 25 per 1000 person-years. In contrast, the mortality rate for younger patients was half that - 12 per 1000 person-years.
 

Half got HIV after 50th birthday
Based on CD4 cell count at the time of diagnosis, they worked out that 48% of the older people with HIV got HIV when they were aged 50 and over. This percentage hasn’t changed between 2000 and 2007.
 

Three-quarters of individuals aged over 50 when they became HIV positive are men, and 54% were gay men.

Source

Reference Smith RD et al. HIV transmission and high rates of late diagnoses among adults aged 50 years and over. AIDS 24: 2109-2115, 2010.
 

1 in 6 Gay Men Recently Infected

posted: 26/07/2010

One in six gay men having a HIV positive test in the UK became HIV positive within the past six months. This is the first result from a new system tracking trends in recent HIV infections in the UK.
 

The Health Protection Agency devised a formula (an algorithm) and method for tracking recent HIV infections. Knowing how many people were recently infected is helpful for working out what is actually happening in the UK HIV epidemic.

The number of recent infections matters because people who are recently infected are far more infectious than at any other time.
 

Tracking recent infections
The new formula and tracking method, called either the Recent Infection Testing Algorithm (RITA) or Serological Testing Algorithm for Recent HIV Seroconversion (STARHS), measures the amounts of certain antibody markers. These amounts change depending on how long ago the HIV infection took place. Amounts below a certain level mean the infection was recent (approximately within the last six months).
 

The RITA / STARHS method is not exact enough to tell an individual when they became HIV positive, because we all vary in how our immune system responds to HIV, but the method is good enough to give rough timings, which is all we need to track what is happening with the epidemic.
The work on this tracking system began in 2008, when the Health Protection Agency rolled-out STARHS as part of the routine public health monitoring of all newly diagnosed HIV infections in the country.
 

Results
The data presented the International AIDS 2010 conference in Vienna that has just ended, came from samples of 2099 people, who broadly represent, demographically and geographically, people newly diagnosed in the UK. The samples were collected between February 2009 and May 2010.
 

Gay and bi men results

Amongst gay and bisexual men, 16.1% of diagnoses were judged to be recent – within the past six months – one in six. There wasn’t any difference between gay and bi men of different ages.
 

Heterosexual results

Among heterosexuals, 6.2% men and 6.8% women were recently infected. This is just one in sixteen heterosexuals being infected within six months of their positive test.
 

There appears to be a trend for recent infections to be more commonly identified in younger heterosexual women (probably due to antenatal testing), but the age variations were not statistically significant. Curiously, in women aged 50 or over, there was a relatively high proportion of recent infections, but this is based on a small number of cases and could be due to chance. But it fits with another recent report from the HPA at the Vienna International AIDS Conference - many long-term heterosexual relationships break up when people are in their 50s, and women, no longer needing contraception, may neglect to consider the need for safer sex - condoms - to protect against STIs such as HIV.

Recently infected heterosexuals were largely people born in the UK. Heterosexual people born in Africa tend to have infection diagnosed later, the majority becoming HIV positive before migration to the UK.
 

Source

Reference: Lattimore S et al. Surveillance of recently acquired HIV infections among newly diagnosed individuals in the UK. Eighteenth International AIDS Conference, Vienna, abstract FRAX01001, 2010.
 

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
 

HIV Superinfection - Not Likely

posted: 27/01/2009

Researchers in America have found no evidence that unprotected sex between people with HIV who are regular partners leads to superinfection with another strain of the HIV virus. They used a long-term study involving 49 people with HIV. No evidence of superinfection was found.

Superinfection and reinfection mean much the same thing and some hyping up of reports happens. Superinfection is reinfection with another strain of HIV, that harms health. Most HIV reinfection causes no apparent harm. Studies show that about 1 in 20 people with HIV who are checked for reinfection for one year show signs of this, so reinfection itself is fairly common. One of these studies was of gay men, the other of women in Kenya. There have been claims in 30-40 case reports of actual superinfection around the globe.

Instead of damage by superinfection, this study found a clear relationship between long-term frequent exposure to their partner’s virus and a strong immune response to that virus, suggesting that repeated exposure eventually builds immunity against superinfection, which is good news.

What harm can superinfection cause?

There’s been a lot of debate about whether unprotected sex between people with HIV can lead to superinfection with the virus. People with HIV are frequently advised not to have unprotected sex even with other HIV-positive people because of a risk of superinfection. Superinfection is reinfection with different HIV, from someone else, that goes bad and damages health. The damage to health is that treatment can get more complicated because the other person's HIV may carry drug resistance, and people may get infected with a more aggressive strain of HIV.

HIV can transmit with it drug resistance even if the person passing it on has never taken any HIV treatment, because the person who had infected them gave them HIV which had some drug resistance.

Aggressive and drug-resistant HIV

Some of the reported cases of superinfection have involved infection with more aggressive or drug-resistant strains of HIV. But this hasn’t always been the case – other documented cases of superinfection don’t seem to have done any harm. So researchers in San Francisco wanted to get a better understanding of the long-term risks of superinfection. What they found makes much clearer the risks of people living with HIV having unprotected sex together. Is there enough evidence of superinfection now to reasonably advise positive people to use condoms when having sex with another person living with HIV?
 

The study looked at changes in the immune system and HIV of 49 people with HIV. All the participants were taking HIV treatment and had an undetectable viral load. All 49 people had HIV-positive partners with whom they were having unprotected sex. The researchers divided the people in the study into two groups, those with partners who had a detectable (20) viral load, and those with partners with an undetectable (29) viral load.

Gay men studied

All 49 are gay men, a fact that is buried deep in the report. George House Trust suspects this is only due to the funding-threat Bush has cast over much HIV research and care for groups of people who are targets of US Christian conservatives' abhorence. Research into protective gels for anal sex has long been held back for the same reason. The early indications are that the new president is moving swiftly to end discrimination around HIV funding. 

Partners show strong immune response

The study found no evidence that any of the 49 men had been infected with another strain of HIV. Instead, they found that men who were exposed to their partner’s HIV developed a strong immune response to it. The men's immune systems were working well and seem to be preventing health damage from the partner's HIV.

Risks now much clearer

This study is important because it makes the risks of superinfection much clearer for the many people with HIV who choose to have unprotected sex with HIV-positive partners, which is known as sero-sorting.

The findings suggest that even where an individual has drug-resistant virus and a detectable viral load, the risks of superinfecting an HIV-positive partner with that drug-resistant virus are low, even for sexually receptive partners (receptive partners are at more risk than insertive ones).

What about people with more partners?

The findings provide no information about what happens if an individual with HIV has sex with many different partners with HIV (because the study only looked at HIV positive gay men and their regular positive partner), but the study’s lead author Chris Willberg, now of the Biomedical Research Centre at the University of Oxford, told aidsmap: “We would speculate that it is regular exposure to the same epitopes that is required to stimulate the responses. What we did not explore is the ability for new [epitope] responses to be developed through exposure.”

George House Trust takes that as a meaningful 'perhaps not, but we didn't study that' because there's evidence (from a study of Nairobi sex workers referred to in the aidsmap article) that superinfection is more likely if the sex is with many positive partners rather than just one.

And because the risks for transmission of HIV are always highest being receptive in anal sex, and then run in this order: being insertive in anal sex, being a woman in heterosexual vaginal sex, being a man in heterosexual vaginal sex, this means gay men who have multiple positive partners take rather more risk of superinfection than the Nairobi women sex workers.

And as the number of positive partners rises, the greater the risk.

It needs another study to answer the 'is there a risk of superinfection with multiple partners' question, and a scientific study seems very difficult to arrange. This is because casual partners cannot be identified in advance; some will have undetectable viral loads but others won't, and this means the numbers needed for such a study would have to be huge; obtaining agreement to take part from many casual partners doesn't seem possible; and some partners would be uncontactable, or refuse to take part. We can't realistically expect to see any scientific answer soon for people who want information now on the risks with multiple partners.

Low risk with more partners seems likely

It's inevitable that some people will speculate and want an informed view, following this reassuring superinfection study. Considering the evidence in the studies, how the body responds, and especially how few cases (just 30-40) have been reported from around the globe, one reasonable view is the risks are low of having much poorer health through superinfection resulting from unprotected sex with multiple partners, even if the partners have detectable viral loads.

This is because sero-sorting with multiple partners among gay men living with HIV is fairly common and has been happening for some years, and if superinfection damage was common, we would be having far more case reports from around the world. Superinfection is big news, so case reports are likely whenever serious problems occur.

However each person needs to make their own decisions on which risks to take when science can't give us an answer. People living with HIV interested in this should discuss with the doctor their advice and interpretation of the evidence. Then make their own decision.

More risk

If the person's health is not so good, exposing the immune system to even more stress from different people's HIV is rather more risky and the health damage could be more significant.   

The far more serious risk from unprotected sex with multiple partners for most positive gay men (whether or not the partners have HIV) is of other STIs. LGV, syphilis, and hepatitis C are particularly likely and harzardous to health when men with more partners already have HIV. Our advisers are always willing to discuss levels of risk and how men can keep these within limits that are comfortable while having a satisfying sex-life, without judging what men do or any associated drug use.

Women too

Aidsmap also asked the study's leading author a really important question many positive women and their partners need answering - do positive women have the same low risk of superinfection from a positive partner as men?

His reply means 'as long as things work in the same way for women, and this looks very likely,' which women and their partners will welcome, but he unhelpfully cloaks this in a long scientific answer: “The most logical explanation for the maintained responses that we observed is that they were driven by receptive exposure to HIV antigen derived from the viremic partner,” Chris Willberg commented. “Therefore, we would expect to see the same results in women also receptively exposed to viremic partners. If the mechanisms responsible for driving the responses in this study are the same as those that drive responses in exposed uninfected individuals, then there is plenty of evidence to suggest women would respond in a similar manner.”

We think 2/10 would be a fair mark for 'ability to communicate' with HIV positive women (and partners), who deserve a clear answer to this plain question. The scientific explanation is exact and complex, yet the actual answer disguised by all these words is clear - but only after repeated reading. Researchers need to make much better efforts to communicate plainly in everyday language the important lessons of their research and expertise, because the public ultimately fund most of the work carried out for our benefit. 17 words give the same answer, but plainly, as over 80.

Other risks - including STIs and pregnancy - remain

For both women and men, unprotected sex can have other health consequences. In the UK, LGV and syphilis are seen much more often in HIV-positive gay men, clearly due to unprotected sex. What’s more, unprotected sex between HIV-positive gay men is also linked to sexual transmission of hepatitis C virus.

Women may also expose themselves to the range of sexually transmitted infections and may become pregnant as a result of unprotected sex. A positive woman wanting to have a baby should talk first with her HIV doctor about when and how best to become pregnant and the ways of minimising the risk of having a positive child. With the right care and treatment this risk is now very low, about 1 in 100.

Further information and reference from aidsmap

The free online journal article

Ending Domestic Violence

posted: 27/11/2008

Around 1 in 4 lesbian, gay, bisexual and transgender people will experience domestic violence at some point in their lives. One in four women experience domestic violence in their lifetime, and domestic violence impacts on every type of people and relationship, including children and heterosexual men.

Tuesday 25 of November marks White Ribbon Day - the global campaign to ensure men take more responsibility for reducing the level of violence against women.

Gay community and domestic violence

Around 1 in 4 lesbians, gay men, bisexual and transgender people will experience domestic violence at some point in their lives. This statistic is very similar to that experienced by people in heterosexual relationships, yet most people think in terms of domestic violence experienced by heterosexual women. They forget that LGBT people live in the same world and experience similar domestic abuse.

HIV and domestic violence

Among people living with HIV, there are no formal studies but anecdotally we know that  people tell us about being assaulted and abused in the home and sometimes of feeling like wanting to. The stress and anxiety and poorer mental health experienced by many people living with HIV can contribute to people losing self control. Having HIV can make people highly vulnerable to attack and abuse in the home.

Many communities, including the LGBT community, put their head in the sand about domestic abuse. However academic research over the last few years, including Stonewall's 'Prescription for Change', has consistently shown that abuse happens and that men and women are suffering on a daily basis from their partners, ex partners or members of their families.
 

Over the next few month’s Broken Rainbow (National Helpline for LGBT people suffering domestic abuse) and the Lesbian & Gay Foundation (LGF) will be highlighting the issue of same sex domestic abuse, culminating in targeted campaigns to coincide with LGBT History month and Valentine’s Day in February.

Melvin Hartley Chief Executive of Broken Rainbow says:
“Since its launch almost 5 years ago, Broken Rainbow has worked hard to change the situation for LGBT people experiencing domestic violence. We offer the only national helpline which provides confidential support to all members of the LGBT community, their families, friends and agencies supporting them. It is run by trained LGBT people who have an understanding of sexual identity issues along with the impact domestic violence can have.”

Andrew Gilliver LGF’s Communications Manager adds:
“If you think you are in an abusive relationship or know someone who is, there are many ways in which you can find help. No one has the right to hurt or harm, and everyone gay, lesbian or otherwise, deserves the right to live their lives freely and with dignity. Whatever you do, whether it is to phone a national helpline, seek out local support, tell a friend or go to the police, reach out for help, there is help there for you.”
 

Broken Rainbow's helpline: 08452 60 44 60 (Mondays 2-8pm, Wed's 10am -1pm, Thursdays 2-8pm)
Broken Rainbow
White Ribbon
LGF