Talking and Telling about HIV

posted: 28/02/2011

There’s a lot of fuss made about how important it is for gay and bi men diagnosed with HIV to tell their sexual partners about HIV, before any sex takes place – which is known as ‘disclosure’.

Telling people whether or not you have an STI / HIV is your choice.

We think it is smarter if every  person in the UK were to talk about HIV and discuss their and partners’ HIV and STI status and risks before sex. But telling others about having HIV is always a choice.

One-sided talking

One major problem is that undiagnosed people, including gay and bi men, rarely ever talk about their own HIV status, but instead expect diagnosed people to always reveal their HIV status.

Some undiagnosed men then decide not to have sex, or decide on less risky sex after the partner says they have HIV.

Conference debates

George House Trust has critically examined the evidence for and against relying on being told HIV status as a way of avoiding getting HIV. Chris Morley, George House Trust's HIV policy expert, issued a challenge to gay men's HIV prevention workers when he gave a detailed presentation at the CHAPS conference last week for England's sexual health and HIV prevention organisations.

The challenge is to tell undiagnosed men that relying on being told by people with HIV is a seriously flawed way to try to avoid HIV. The HIV risk run by men expecting disclosure is simply too high. The challenge was also to help undiagnosed men be more respectful to anyone who does disclose having HIV. Some disclosing men with HIV are then shamed, abused, rejected, or worse.

Talking about HIV happens very unevenly and the expectations of disclosure put an unbalanced burden on people with HIV.

Dysfunctional Disclosure

The far bigger problem however, is that relying on being told, and being told accurately, is a highly risky way to manage anyone's HIV risks.

Only men diagnosed with HIV have HIV status information that is at all reliable.

Depending on men to tell you they have HIV puts you at a big HIV risk. Disclosure doesn't work at all well as a way of staying HIV negative. 

• 1 in 3 gay and bi men have never had a HIV tested - so untested, can't tell anyone anything useful about their own HIV status
• Men who have been tested usually only have information that is past its sell-by date
• Many men have had condomless anal sex since they had their last negative HIV test. An MOT certificate saying your car was roadworthy is no guarantee of future safety after you have had a crash. In the same way, a negative HIV test result becomes worthless once you have had unprotected sex.
• The only dependable information is from men who have been diagnosed with HIV to tell you this; but not all diagnosed men disclose in all situations; for example disclosure by diagnosed HIV+ men is less common in gay saunas and clubs.

George House Trust is also making a second presentation, about cuts in legal advice and representation for people with HIV. 

HIV Legal Advice Services
Among the hundreds of cuts, one cut would remove most legal aid for advice and representation at courts and tribunals. £450 million is to be slashed from budgets for advice, such as provided by Citizens Advice, Manchester Advice, Law Centres and other organisations, for immigration and asylum, welfare benefits, housing, employment and most discrimination cases.
 

This will affect millions of people a year, and you can tell things will become really bad, because even the Judges’ Council has gone public with its objections.

HIV Talking and Telling - George House Trust discussion for CHAPS-14 conference, Manchester  

HIV Advice Services - George House Trust discussion for CHAPS-14 Conference, Manchester

CHAPS-14 Conference, Manchester, March 9-11th

Image - Let's Talk HIV - Swedish language HIV site
 

USA Prevention Treatment Gay Guidelines

posted: 08/02/2011

The first guidelines for HIV negative gay and bisexual men wanting to reduce the risk of getting HIV by using the anti-HIV drug Truvada have appeared.

Taking HIV treatment drug(s) before sex is called pre-exposure prophylaxis (PrEP) and it is not guaranteed to work.

Just two months after the first positive results showed that Truvada can sometimes help, this ‘interim guidance’ has very quickly appeared.
 

The USA public health body, the Centers for Disease Control (CDC), were worried that unofficial, poor use of Truvada and bad habits would grow up if they didn’t put out some guidelines quickly.
 

Prescriptions with detailed support
In the guidelines prescriptions should only be given for 90 days at a time, with HIV testing, adherence counselling, sexually transmitted infection check-ups, sexual risk counselling and condoms provided before new prescriptions are issued.
 

Only if HIV risk ‘substantial’ and continuing
The guidelines state that PrEP should only be provided for men who have sex with men, specifically those who are “at substantial, ongoing, high risk for acquiring HIV infection”.
Pre-exposure prophylaxis involves HIV-negative people taking antiretroviral medications in order to reduce their risk of acquiring HIV. In November, a study conducted with gay and bisexual men in six countries showed that daily use of the two drugs tenofovir and FTC (combined in one pill as Truvada) reduced the risk of infection by 44%.
 

However many of the gay and bisexual men participating in the trial did not take the pills each day, as prescribed. In men who did take the drugs consistently, results seemed to be much better. In men with very poor adherence, results were worse.

However extensive analysis of the adherence data from the trial has not yet been completed, nor have the trial results been replicated in other settings.
 

The CDC only supports using Truvada when it is used almost exactly like it was in the trial. That is why they are limiting its use now gay and bisexual men at high risk of getting HIV.
 

Truvada indicators
The guidance gives quite a broad indication of which men PrEP may be suitable for, citing only lack of condom use in combination with “frequent partner change or concurrent partners in a geographic setting with high HIV prevalence” as examples.
 

Truvada only
The CDC says that antiretrovirals other than Truvada should not be used for PrEP and that the same daily dosing schedule that was employed in the trial must be followed. Therefore, ‘intermittent’ dosing (i.e., before or after sex) is not endorsed.
 

Adherence and continuing prevention support
Moreover adherence support must be a “routine component of any PrEP program”. It should be provided before PrEP is issued, and then at least every 90 days.
 

Similarly, PrEP should only be delivered “as part of a comprehensive set of prevention services” that includes risk-reduction counselling, ready access to condoms and the diagnosis and treatment of sexually transmitted infections. These activities should take place each 90 days, before a new prescription is issued.
 

HIV test first
Before PrEP is provided, clinicians must also check that the patient is HIV-negative. If he has any signs or symptoms that may be linked to HIV seroconversion, RNA testing is recommended. He must also be screened for sexually transmitted infections and hepatitis B, and have his kidney function assessed (Truvada can sometimes harm the kidneys).
 

Other tests for side-effects are required after three months and then annually. Any serious adverse events should be reported to the Food & Drug Administration (FDA).
Cost will be a central concern. In the USA medical insurance companies are unlikely to pay for this prevention use of Truvada but if men have the cash USA doctors can prescribe it. A month’s supply costs around $1000, and USA patients would also have to pay for counselling, side-effects monitoring and doctors appointments.
 

Source

Smith DK et al. Interim Guidance: Pre-exposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men. Morbidity and Mortality Weekly Report 60: 65-68, 2010.

 

Risks and HIV Status

posted: 26/10/2010

Gay men using London gyms are revealing more about choosing their partners and taking risks with anal sex. The latest annual sex risk survey of gay men at London gyms has appeared. 36% of the 648 men taking part in 2008 had anal sex without condoms in the previous year. Condomless anal sex is becoming more common, but this headline “masks a more complex picture,” which varies with HIV status, the researchers say.
 

Same HIV status or different status: more risks
Men are now having more sex without condoms with partners who have the same HIV status, than with men whose HIV status is different or unknown to them. But there are also more men reporting sex without condoms with a main partner whose HIV status is unknown or different.
 

1 in 3 taking risks but more choose same HIV status partners
The first study, in 1998, found 24% of men had unprotected anal intercourse in the previous three months. By 2008 this was up to 36%. But in both the two latest surveys (2005 and 2008), more men report having unprotected sex with men of the same HIV status as themselves (“sero-sorting”) than with men of unknown, assumed or different HIV status. In 2008 21% reported condomless anal sex with men of the same status and 16% reported this with men of unknown, assumed or different status.
 

Some positive men choosing positive
Among HIV-positive men in 2008, 14% sero-sorted (chose a partner who is also HIV+) their casual partners. 10% of the HIV-positive men have a main partner who also has HIV.
 

Negative men rarely choose casual partners by HIV status
Among men who reported that their last HIV test was negative, less than 2% chose casual partners who are also HIV negative. However 21% had unprotected sex with a main partner whose last HIV test was also negative. The proportion of supposed HIV negative men reporting condomless sex with men who also last tested HIV negative has risen to 21% since 1998, when 12% reported it.
 

Test together or just talk?
The researchers are worried about how HIV-negative men decide their main partner is also HIV negative. While four in ten men took the HIV test together, the others only talked about their status. This is not good enough, because the longer the time since the last test and the risks taken since that test mean the test result may now be wrong.
 

Men’s relationship risks
Men’s main relationships seem to be where more risks are now being taken, although the numbers are low. There have been significant increases in the numbers of men reporting having unprotected sex with a main partner of unknown, assumed or different HIV status between 2005 and 2008.
 

Positive men risks
Among HIV positive men, 2.5% reported having unprotected sex with a main partner of unknown, assumed or different HIV status in 2005, and it was 8.1% in 2008. For about half the positive men, in fact their partner’s HIV status was known to be HIV-negative.
 

A significant proportion of HIV-positive men (19%) report unprotected sex with casual partners of an unknown or assumed HIV status, although this has fallen a lot compared with the earlier surveys.
 

Negative men risks down
Fewer than 6% of HIV-negative men report unprotected sex with casual partners of an unknown or assumed HIV status, the lowest level in these gym surveys. The researchers comment: “This is an encouraging trend and is likely to reflect consistent and sustained health promotion campaigns targeting gay men.”
 

Summing up, the researchers say that their data “suggest that main partners may have become an important source of HIV risk among London’s gay men.” They recommend that more health promotion campaigns should focus on HIV risk within relationships and on HIV testing among couples.
 

Source with reference details