Bare Porn Costs - African HIV

posted: 01/09/2009

A documentary ‘Hardcore Profits’ that was shown last night on BBC2 laid bare the cost of porn for Africans. HIV infections and rape follow directly from viewing western bare (condomless) porn. It’s available dirt cheap, almost everywhere. The porn industry has yet to acknowledge its part in driving up the global HIV epidemic.

The documentary maker Tim Samuels tells us -

The moment porn truly stopped being fun came in a remote Ghanaian village – mud huts, barefoot kids, no electricity. The BBC series I was making about the impact of porn, had led me, via Los Angeles (LA) to Ghana. One of the unforeseen consequences of globalisation is the shocking effect that western porn is having in parts of the developing world.

The village has no electricity, but that doesn't stop a generator from being wheeled in, turning a mud hut into an impromptu porn cinema – and turning some young men into rapists, with villagers relating chilling stories of assaults taking place straight after the film's end. In the nearest city, other young men are buying bootlegs copies of the almost always condom-free LA-made porn – copying directly what they see and contracting HIV. The head of the country's AIDS commission says porn risks destroying all the achievements they've made. It's a timebomb, he says.

The concerns aren't theoretical – I met young fathers with HIV whose only sex education came from LA, women living in the villages subject to post-screening abuse, and even a shy teenage virgin who has written to a porn outfit in California asking to star in their films (his return address was care of the local church in Accra).

The porn producers aren't deliberately pushing their products into Africa. But the tide of black market DVDs on sale at street markets and hardcore clips viewable at internet cafes is almost unstoppable. Surely this multibillion-dollar industry needs to take some responsibility for the human costs?

Bare porn as sex education
Since the only sex education some people in places such as Ghana are getting is via porn films, there is a decent argument for the porn industry to produce more films where performers use condoms. In LA, where the majority of the world's porn is still shot, only one company routinely makes such films. The condom-only policy adopted following an industry HIV outbreak five years ago lasted just months.

Massive profits for mobile phone companies and hotel chains

If the ambition is to put more condom-using porn into circulation, which will then more likely end up in those street markets or cafes, some serious multinationals could throw their corporate weight behind this. Hotel chains – among the biggest broadcasters of adult material – have not used their immense clout to insist on greater condom use – much to the dismay of the porn-star STD-testing clinic in LA.

Mobile phone firms are also surreptitiously making jaw-dropping amounts of money from showing adult content on their handsets. Could their ideas of corporate responsibility take on a latex dimension? Might it actually be that ridiculous for the porn industry itself to adopt a spot of corporate responsibility? These are, after all, major businesses replete with HR departments and plush offices nestling next to mainstream film companies. Bankroll sex safe campaigns, harness the allure of their top stars, maybe even make bespoke films for the developing world which educate as well as titillate. Doing nothing, and leaving western porn to march untrammelled into Africa and other places, is a deeply unattractive prospect.

Tim Samuels's 2 part series, Hardcore Profits, started last night (Monday 31 August) on BBC2; part 2 is 9pm next Monday. You can watch part one online on BBC iPlayer here. The part of the documentary about porn's impact in Ghana starts about three quarters of an hour into the one hour long programme.
 

Source

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

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.

You can sign up for NAM's CROI conference dailiy update here

Oral Sex, Tiny HIV Risk

posted: 17/12/2008

For about 20 years we have said oral sex is low-risk, not no-risk for HIV transmission. Now researchers have tried to say how low the risk really is. This is not so easy to check as you might think.

The risk of HIV transmission during oral sex is very low, but not zero, conclude researchers from Imperial College and the London School of Hygiene and Tropical Medicine. They tried to find all the studies, but found that the lack of data meant they still can't make a broad estimate for the transmission risk through oral sex.

They started with a systematic review (an analysis of all the medical research that meets their standards). The studies reviewed include data from heterosexual, lesbian and gay couples, covering both fellatio (oral sex on a man) and cunnilingus (oral sex on a woman).

Only 10 studies count

Only ten studies were judged to be good enough to include in the review. All were from Europe or North America, and only three used data from after HIV combination treatments became widespread.

Problems

The researchers point out the many problems with measuring oral sex risks for HIV.

• Very few people only have oral sex.
• If a person has both unprotected oral sex and unprotected anal or vaginal sex, and acquires HIV, their HIV infection is automatically attributed to the more risky anal or vaginal route, not to oral sex.
• Data on individuals’ self-reported sexual behaviour is hard to collect accurately, especially because people tend to give more socially acceptable answers (i.e. pretending to have been "good" and not "admitting" sex without condoms).
• Studies frequently group all oral sex practices together, without separating out the oral sex acts by who was doing what to whom, which person has HIV, if there is ejaculation in the mouth or not, and if so, the spit or swallow choices.
• Studies of serodiscordant couples (where one person is HIV-positive and the other is not) are likely to include people with well-controlled viral load, meaning that they are much less infectious than during primary infection (the first few weeks after HIV infection when people are the most infectious they will ever be). Oral sex transmission is more likely during primary infection. Oral sex transmission of HIV is also more likely when one or both have certain other sexually transmitted infections (STIs), especially those STIs that have sores. 
• Studies which do identify a risk from oral sex are more likely to be published and reported than those which do not, because of the interest and comparative novelty of such a finding.

Estimates of the per-partner transmission risk - zero to 20%!
Five of the studies provided estimates of the risk of multiple oral sex acts during the life of a sero-discordant relationship.Three of these studies gave that estimate as zero – no transmissions were reported.

The fourth study provided a figure of 1% for receptive fellatio.

The fifth study, from Sweden, provided a much higher estimate of 20%. However the sample was very small (ten couples reporting oral sex as their only risk factor), and the review authors comment that the high estimate may be due to under-reporting of higher risk activity, or simply due to chance. Moreover, this is the only reviewed study which identified any HIV transmission among heterosexuals that could be attributed to oral sex.

Estimates of the per-partner incidence, per 100 person years
Three of the studies also reported estimates which calculated the transmission risk of multiple oral sex acts, but with the duration of the relationship stated. In each case, the estimate was zero.

Estimates of the per-study-participant transmission risk
Three further studies followed HIV-negative people who reported unprotected oral sex as their sole risk factor. However the authors note that these studies have additional methodological limitations: the number of sexual partners and their HIV status is not known. This implies that the findings cannot be transferred to other populations where numbers of partners and HIV prevalence are different.

Two American studies gave estimates of 0% and 0.4% respectively, and the more recent Canadian Omega cohort provided a figure of 0.5%. Each study was conducted with gay and bisexual men.

Estimates of the per-act transmission risk
Three studies attempted to calculate the risk of HIV transmission during a single act of oral sex.

Two studies both provided zero estimates – no transmissions were reported.

The third study is Vittinghoff’s often cited paper which used data from American gay or bisexual men who reported multiple risk behaviours. Mathematical models were employed to estimate the risk of different sexual acts, and unprotected receptive oral sex with ejaculation was calculated to have a 0.04% risk of HIV transmission. However the review authors note that this estimate is based on sex with both infected and uninfected men – if the researchers had been able to exclude sex with HIV negative partners, the figure would have been higher.

Conclusions
The authors note the paucity of data to inform this review. Reliable estimates would be important for prevention workers and clinicians advising people on the relative risks. Moreover, because of the low risk of transmission, "large and expensive studies" would be required to provide more precise estimates.

They also comment: "The fact that infected study participants with solely this exposure have remained difficult to identify may suggest that indeed the contribution of orogenital intercourse to HIV incidence remains low."

Nonetheless they do recommend that "individuals should protect themselves using condoms or dental dams to minimise this small risk."

George House Trust comment - STIs and gum disease raise risks

After 20 years we are no nearer answering the oral rex risk question with scientific accuracy. The balance of the evidence is clear - the risk is minimal.

But from other research we know that the risk of HIV (and STI) transmission during oral sex is far higher when people have other STIs (herpes, syphilis, gonorrhoea included) either in their mouth or genitals. It is also higher when people have gum disease and other mouth and throat infections. Both STIs and gum disease increase the risk of transmission during oral sex because they can provide an open pathway into the bloodstream for the HIV virus.

We can reasonably expect that oral sex risks are highest in these situations, especially when people are in the much more infectious primary stage of infection (within the first two months of themselves becoming infected). For people at other times, and especially for those people on treatment with undetectable viral loads, the transmission risk would seem to be very close to zero.

In terms of prevention priorities, fretting about the tiny oral sex risks is a diversion from the things that would really make a difference to the annual numbers becoming infected, including consistent condom use in anal and vaginal sex, reducing the numbers of people with undiagnosed HIV as far as possible, and actions which prevent transmissions during the most infectious first few weeks.

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