USA - Treatment as Prevention

posted: 10/12/2009

The USA has joined the list of countries producing national statements about how effective HIV treatment can make passing on HIV during sex very unlikely. 

The USA statement uses much the same evidence as the earlier Swiss, French and German statements on HIV treatment as prevention that we have reported. However, it is a lot more cautious, urging continued consistent condom use.

"In summary, for couples in which one member is HIV-infected, treatment of the infected partner with effective ART and suppression of viral load to undetectable levels should greatly reduce the risk of transmission to the uninfected partner. However, this risk is not eliminated and it may not be maximally reduced at all times due to some of the factors discussed above. Moreover, the likelihood of transmission may be expected to increase with repeated exposures over time."

"In a model which estimated transmission risk in the setting of suppressed viral load (<50 copies/mL) without intercurrent STIs, the number of expected transmission events occurring within a population of 10,000 serodiscordant couples over 10 years was estimated to be 215 for female-to-male transmission, 425 for male-to-female transmission, and 3,524 for male-to male transmissions [31]."

"In a meta-analysis of data from 11 cohorts including 5,021 heterosexual couples observed no transmissions among persons receiving ART with a viral load of <400 copies/mL; however, analysis of the data was compatible with the possibility of one event per 70 person-years [32]. For this reason, it is important that individual couples recognize the risk, and use additional preventive methods (e.g., condoms) in order to further minimize the chance of transmission."

So they advise condoms for heterosexual couples to prevent a 1 in 70 person years possibility of transmission.

This statement and advice comes from the US Centers for Disease Control.

Effective HIV treatment where the viral load is undetectable reduces the risk of HIV transmission but some slight risk remains. The risk is higher for gay men than most heterosexual people, and sexually transmitted infections especially raise the risk of transmission.

US Centers for Disease Control statement Effect of Antiretroviral Therapy on Risk of Sexual Transmission of HIV Infection and Superinfection [read on webpage] OR download it as a pdf

French statement

German statement

Swiss statement

German Risk Statement

posted: 27/04/2009

We have had the Swiss Statement, now their neighbours, the Germans, have issued their own on the risks of HIV transmission from people taking HIV treatment successfully.

The Swiss told us last year that people on HIV treatment, if they meet certain conditions, can be considered uninfectious. Now the largest HIV voluntary sector organisation in Germany, Deutsche AIDS-Hilfe, has issued a paper largely supporting this statement.
 

The German paper describes sexual transmission, where the HIV-positive partner is

• adhering to effective combination therapy,
• has had an undetectable viral load for the last six months and
• has no sexually transmitted infections,

as ‘unlikely’ and describe this as being as effective as using condoms. They add that it is also important that there is no other damage to either person’s mucous membranes.

Stable, long-term different-HIV-status relationships
Both the German and Swiss organisations say their statements are relevant to stable, long-term relationships where one partner has HIV. After the couple has made a decision, based on good information and advice, regular viral load testing and sexual health check-ups are recommended.
 

HIV is sometimes found in semen even though it is undetectable in blood.

However, Deutsche AIDS-Hilfe argues that relying on effective treatment as a means of HIV transmission prevention is a realistic HIV prevention approach, and that individual couples already  make decisions about the level of risk they take.

Read the English language version of the German statement

Swiss statement report

Call for Treatment as Prevention

posted: 10/03/2009

Pioneers in HIV research now call for testing of a strategy that uses treatment-as-prevention deserves testing out.

One of the pioneers of HIV research, former Harvard retrovirology professor William Haseltine, said today that universal testing and treatment now offers the best hope of controlling the HIV pandemic.

Writing in the news magazine The Atlantic, Haseltine said that three other authorities involved in the discovery of HIV – Robert Gallo, Max Essex and Robert Redfield – have reached the same conclusion.

“History has shown that epidemics can be controlled, even in the absence of a vaccine,” he says. “Both syphilis and tuberculosis were pandemic at the end of the nineteenth century, and both epidemics were controlled by effective diagnosis and treatment.”

Global call for new treatment-as-prevention strategy

“I recommend that WHO, PEPFAR and the Global Fund begin studies to assess the effectiveness of universal testing and early treatment for the prevention of HIV transmission,” he urges.

Vaccines doubts

At a recent seminar on global governance challenges at the James Martin 21st Century School at Oxford University, Professor Jonathan Weber of London’s Imperial College said that after 27 years in HIV research, he no longer believes a vaccine to be achievable. Instead he believes that population-based antiretroviral therapy (PopART) is the only strategy currently available that holds out the prospect of HIV eradication.

WHO - S Africa and UK

Population-based treatment, or maximising the numbers testing and on treatment, is a subject of growing interest to researchers. Last November the World Health Organization published details of a mathematical modelling exercise which suggested that if all people in South Africa could be diagnosed and begin antiretroviral treatment within a year of infection, the number of new infections could be reduced by 95% within ten years. It also looked at its use in the UK.

Montreal conference calls

Then at the Sixteenth Conference on Retroviruses and Opportunistic Infections in Montreal, Canada earlier this month, two studies of transmission risk in HIV-discordant couples were presented. One showed no cases of transmission in couples where the HIV-positive partner took antiretrovirals, while the other showed an 80% reduction in transmission risk.

Christophe Fraser, an epidemiologist from Imperial College, London, warned the confererence that the striking effect of universal treatment in mathematical models might not be replicated in real life if it proved less than 99% effective, and called for careful examination of the assumptions in the WHO models by other epidemiologists before policy is made.

Brighton CHAPS conference calls

And the recent UK gay men's sexual health conference CHAPS, in Brighton debated this. George House Trust's policy expert Chris Morley was one of a panel of speakers debating Treatment as Prevention.

Many people with HIV on treatment with an undetectable viral load are already rethinking condom use and telling partners. There are still some risks of HIV transmission - particularly if either partner has a sexually transmitted infection. But in ideal circumstances, it is pretty clear that the transmission risks with an undetectable viral load are not much worse than with using condoms consistently. People have a right to know the facts and to choose how to manage transmission risks and disclosure to suit themselves.  

Source

Swiss Court Frees HIV+ Man

posted: 10/03/2009

In the first ruling of its kind in the world, the Geneva Court of Justice has freed a man given 18-months prison for exposing someone to HIV.The court ruled that the risk of HIV transmission while the man was on treatment was far too low to justify the conviction.

In Switzerland, public health law effectively made it a crime simply for people with HIV to have any  unprotected sex. However this court has now changed this. It accepted expert testimony from Professor Bernard Hirschel – one of the authors of the Swiss Federal Commission for HIV/AIDS consensus statement on the effect of treatment on transmission – that the risk of sexual HIV transmission during unprotected sex on successful treatment is 1 in 100,000. It ruled that this level of risk was far too low to keep unprotected sex a public health crime.

The case began in Lausanne in 2007, when a court sentenced the HIV-positive man, originally from the Democratic Republic of the Congo, to a suspended 28-month sentence for having unprotected sex, without telling his woman partner his HIV status.

Swiss HIV Law

Under the public health parts of the Swiss criminal law, Article 231 allows prosecutions against HIV-positive individuals for having unprotected sex, with or without disclosure. The UK doesn’t have a public health criminal law about disease exposure. Prosecuting and criminalising public health was dropped in the UK because it goes against the principle of encouraging people to come for testing and treatment. Criminalising public health drives people with health needs underground and protecting public health becomes far more difficult.

People with HIV in Switzerland can also be prosecuted under Article 122, for an attempt to engender grievous bodily harm. This makes it an attempted grievous bodily harm to have unprotected sex, even if there is no HIV transmission. People with HIV in Switzerland are jailed simply for having unprotected sex. This can't happen under English law. Here HIV transmission has to take place before the charge of "grievous bodily harm" can be made. There is no English crime of attempted grievous bodily harm.

Deborah Glejser of Swiss community HIV organisation, Groupe SIDA Genève, explains that although this public health law could be used even more harshly, to prosecute unprotected sex even when HIV status has been disclosed, in practice, the Swiss only prosecute HIV exposure without disclosure. Suspended sentences are normal so this man’s imprisonment was unusual.

Trial judge refused to consider Swiss statement

A second complaint last year led to the man standing trial again in Geneva in November 2008. According to a report in The Geneva Tribune, an expert medical witness had testified that although treatment greatly reduces the risk of transmission, there remained a residual risk. Although the man's lawyer had put forward the statement by the Swiss Federal Commission for HIV/AIDS as evidence, and Geneva's deputy public prosecutor wanted to suspend the hearing to consult with the Swiss HIV Commission, the lower Geneva court refused to allow this. This made it his second conviction so he was sent to jail for 18 months, in December 2008.

This clearly annoyed the deputy Public Prosecutor who felt justice was not being done or being seen to be done. The court refused to consider the evidence even the prosecutor thought was relevant. We are left with the suspicion that a white Swiss native would have not been jailed for 18 months like this black African migrant. The British pattern of a disproportionate numbers of migrants being jailed for HIV crimes is found across much of the globe

It's Super-Public-Prosecutor to the rescue

Late in February the deputy public prosecutor came to the rescue and told the Geneva Court of Justice that he was convinced by the Swiss Federal Commission for HIV/AIDS that the risk of transmission for an HIV-positive individual on successful treatment was less than 1 in 100,000. Under the circumstances he wanted to appeal so as to withdraw the charge and for the court to cancel the conviction.

On Monday, the Geneva Court of Justice acquitted the man, who was freed  after almost three months in prison. Geneva’s deputy public prosecutor, Yves Bertossa, called for the appeal, told the newspaper Le Temps that although there is still some debate regarding the slight risks of transmission in people on successful treatment this should not be used unfairly: "One shouldn't convict people for hypothetical risks,” he said.

Swiss statement did what it set out to do

Professor Hirschel said that he was very pleased with the outcome. It was, he said, the main reason that he and his colleagues issued their January 2008 statement of advise for courts and prosecutors.

The Swiss panel has had enormous global attention and a great deal of criticism for openly talking about and applying the lessons of modern HIV treatment to the lives of people living with HIV. Swiss HIV clinicians wanted to put a stop to much of the jailing of people with HIV - simply for having unprotected sex without any HIV transmission.

Deborah Glejser of Groupe SIDA Genève added that Monday’s ruling means that, in Switzerland, HIV-positive people on treatment which is working properly should no longer be prosecuted for having unprotected sex. She hopes that this ruling will help people in other countries that prosecute HIV exposure – and she’s been contacted by many already.

Hopes for fall in global prosecutions

Last May, a five member US Court of Appeals for the Armed Forces panel rejected, but only by a narrow majority, an appeal by an HIV-positive soldier who had previously pleaded guilty to HIV exposure, following unprotected sex with two women without disclosing his HIV status. And last July, a Canadian court considered and rejected the Swiss statement in the case of a man charged with having unprotected sex with six women.

Following Monday's ruling, however, Geneva’s deputy public prosecutor, Yves Bertossa, believes it is only a matter of time before other jurisdictions realise that prosecutions for HIV exposure should not take place when the accused is on successful antiretroviral therapy. He told Radio Lac: “There are some medical advances which can change the law. I think that in other [parts of Switzerland] or in other countries, the same conclusions should apply to their laws."

source

Undetectable But Infectious?

posted: 10/02/2009

One of the hottest topics over the last twelve months has been the infectiousness (or otherwise) of people taking HIV treatment who have an undetectable viral load in their blood.
 

The debate was kick-started a year ago by what’s come to be known as the “Swiss Statement”. This said that individuals taking HIV treatment who had an undetectable viral load and no sexually transmitted infections were essentially non-infectious to their partner in a monogamous heterosexual relationship.
 

The authors of the Swiss Statement noted that effective HIV treatment suppressed viral load to undetectable levels in both blood and semen.
However, two studies presented to the CROI Conference in Montreal, Canada, have confirmed that HIV can be undetectable in blood, but still detectable in semen in a minority of men, even without any STIs.
 

1 in 7 "undetectable" men have detectable and infectious semen

A Canadian study involving 25 men found that undetectable viral load in the blood, was found with detectable virus in about 1 in 7 semen samples. The virus in semen was potentially infectious.
 

Semen virus sometimes blips and becomes detectable

The study also showed that viral load in semen occasionally “blipped” to detectable levels.
About a third of men who’d been taking long-term HIV treatment that suppressed viral load to undetectable levels in the blood occasionally had detectable HIV in their semen.

A larger French study looked at paired blood and semen samples from 145 men taking HIV treatment. Viral load was undetectable in 85% of these paired samples. But in 3% of samples, HIV was undetectable in blood and detectable in semen – viral load in these samples ranged between 250 and 1200 copies/ml.
Most of these detectable samples were “blips”, and the French researchers found good levels of anti-HIV drugs in the patients’ semen.
 

There was discussion about the implications of these findings, in particular if the levels of HIV found in semen involved a significant risk of HIV transmission. There was only one case of HIV transmission in the French study, but this involved a patient who wasn’t taking his treatment properly.
 

Swiss should not claim undetectable people can never transmit

However, both sets of researchers concluded that an undetectable viral load in blood doesn’t always mean that viral load is undetectable in semen, and that successful HIV treatment doesn’t entirely eliminate the risk of HIV transmission. So the Swiss statement was a bit too dogmatic - transmission is possible but seems really unlikely.

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