Treat Gay Swiss at Diagnosis?

posted: 19/04/2010

Swiss researchers are now suggesting that all HIV positive gay / bi men should be offered HIV treatment straight after diagnosis, to control the Swiss HIV epidemic among gay and bi men. They found that most new HIV infections amongst gay men in Switzerland came from men who have had HIV for some time, and all of these men had stopped taking treatments. In this Swiss study, HIV rarely came from newly infected men.

Treat to prevent
The investigators believe that their findings support “early” and “continuous” use of HIV treatment by gay men, and suggest that this could profoundly slow the HIV epidemic in this population.

We think the Swiss should concentrate instead on finding out why these men have stopped taking treatments and are having unprotected sex, and deal with those.

Treating everyone at diagnosis would help cut the numbers of new infections, but men with HIV have every right to choose whether to take anti-HIV treatment. No one has the right to force HIV treatment on people, even if this will help reduce the number of people getting HIV.

The UK national treatment guidelines advise people to start HIV treatment when it is best for that individual with HIV, not as a normal means of HIV prevention to protect others.

Infection clusters
An in-depth knowledge of the dynamics of HIV transmission among gay men helps us plan effective prevention campaigns. Swiss investigators (using the Zurich Primary Infection study and the Swiss HIV Cohort study) used phylogenetic analysis to discover clusters of closely related-HIV transmissions among recently infected gay men.

Stopped treatment
They mapped the clusters of HIV transmissions amongst gay men recently infected with HIV. They found only two men whose HIV came from men who had only just got HIV themselves. Almost every Swiss man’s infection came from a guy who had HIV for at least one year, and it was always from a man who had stopped taking HIV treatment. “Infectiousness during chronic infection was quite high in this population”, comment the investigators.

They found identified six transmission clusters involving 20 men from the Zurich cohort and eight individuals from the wider Swiss cohort. Only two infections appeared to originate in individuals with very recent HIV infection. The rest had their source in chronically-infected individuals who had stopped taking HIV treatments. These men had viral loads ranging from 314 – 1,690,000 copies/ml.

The investigator’s first analysis suggested that one man who was taking HIV therapy and had an undetectable viral load may have transmitted HIV to his partner. However, further genetic analysis found three other patients with more closely matched virus – one of whom was the source of the HIV.

“We detected a remarkable proportion of new infections originating from … patients …. already in their chronic phase”, comment the investigators. They add, “These findings argue strongly for early, continuous antiretroviral therapy in sexually active HIV-infected men who have sex with men. This strategy, most likely, will have a profound impact to reduce further spread of HIV.”

George House Trust comment

The Swiss authors don't explain how treating every gay / bi man with HIV will work when almost all Swiss the infections in this study come from men who have chosen to stop taking their treatment. It is wrong to force treatment on people.

We think it makes far more sense for the Swiss to understand why these men

• stopped taking all HIV treatment
• are having unprotected sex

and then to provide better treatment and prevention support.

Local solutions for each local epidemic

Treating every gay and bi man with HIV might just be the solution for the gay / bi HIV epidemic in Switzerland, but it is not likely to be the best solution for England. For example in England we know that a significant proportion of new gay / bi HIV infections come from men who were just infected themselves.

Source with reference

HIV - Treat to prevent?

posted: 06/04/2010

The use of HIV treatment for preventing HIV is a hot – and controversial – topic. Now researchers are saying people with HIV should not stop using condoms and start depending on HIV treatment to protect their partner until you have taken treatment and the viral load has been undetectable for at least 12 months.

 
Some, perhaps most, people who are taking HIV treatment, who do not have sexually transmitted infections and who have an undetectable viral load, are not infectious to their sexual partners.

Some of the research suggests that taking HIV treatment and keeping an undetectable viral load is at least as good as using condoms in preventing HIV. Not everyone agrees, and there are heated debates about this at HIV conferences.
 

The debates started about two years ago with what is now called the Swiss statement - it was followed by broadly similar statements from France, Germany and the USA.

Reliably undetectable?
Danish researchers wanted to see if people taking HIV treatment can rely on their viral load remaining undetectable. They looked at the viral load results of every person in Denmark who was taking HIV treatment. Research shows that HIV transmissions are very rare if a person had a viral load below 1000 copies/ml. So they assumed that everyone taking HIV treatment with a viral load above this is potentially infectious. They then calculated the amount of time that people taking HIV treatment had an ‘infectious’ viral load of above 1000.
 

Reliable for most

For people who reached an undetectable viral load, it stayed undetectable 99.5% of the time.
But during the first year of HIV treatment, viral load can suddenly increase to detectable levels – this happens for about 5% of the time. People won't know when their viral load has taken an upward, detectable, blip when HIV transmission becomes more likely.

The risk of transmission was especially high during the first six months of HIV therapy, when 8% of the time was spent with a viral load above 1000 copies/ml. During the next six months, viral load was at potentially infectious levels for a little over 1% of the time. After the first year viral load was only above the potentially infectious threshold for an average of 0.6% of the follow-up period. After five years, only 0.03% of the follow-up period was above 1000 copies.

Different routes of transmission do not seem to make a difference - except for injecting drug users who had a potentially infectious level of viral load 1.5% of the time. The researchers belive this is because of poorer treatment-taking among injecting drug users.

Wait until viral load stays undetectable for 12 months

They therefore think that the Swiss recommendation about using treatment for HIV prevention should be tightened. They believe people should not swop condoms for treatment until there has been an undetectable viral load for at least twelve months, twice as long as suggested in the Swiss statement.
 

Sexual Transmitted Infections and viral load

Sexually transmitted infections can cause undetectable viral loads to suddenly become detectable - especially in the genital fluids. We measure all our viral load samples from the blood but what passes on HIV is HIV in the genital fluids. Many people have undetectable HIV in the blood but can have a detectable viral load in the genital fluids - and these are the ones that transmit HIV in sex. Sexually transmitted infections cause detectable genital viral loads and make us more infectious. Some experts say that among groups of people with high rates of sexually transmitted infections, such as gay and bi men with HIV, undetectable viral load is too unreliable to judge your risk of passing on HIV.

Swiss reminder

The debate on treatment as prevention was kick-started a little over two years ago by the release of what is known as ‘the Swiss statement.’
Senior Swiss HIV doctors and researchers said that HIV-positive individuals who were taking HIV treatment were not infectious to their sexual partners if:

• Their viral load had been undetectable for at least six months.
• They took their HIV treatment properly.
• They did not have any sexually transmitted infections.

Source

image from the HIV Prevention Justice Alliance blog

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.  

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