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.

 

Testing In European Gay Sex Survey

posted: 26/01/2011

In June we asked gay and bi men to take part in the first Europe-wide web survey of HIV and sexual health risks and needs. Thank you to all who joined in.The first report is out now; it became the world’s largest survey of gay and bi men. 180,000+ gay and bi men took part and 10% were from the UK – 18,400 men.
 

Behind on testing
The UK has Europe’s fastest growth in HIV but the survey tells us gay men in many other countries are testing more often. More men tested in over a dozen countries last year than in the UK, including men in Spain, Italy, Portugal, France, Belgium, Netherlands, and Russian men.
 

Two out of three gay and bi men in the UK haven’t had a HIV test in the last year as recommended. And around 1 in 3 UK gay and bi men have never taken a HIV test.
 

When did you test?

If you are a gay or bi man who has not been diagnosed with HIV, when was the last time you had a HIV test? Annual HIV tests make sense in NW England because around 1 in 10 men on the local scene have HIV, with about one third of those with HIV not knowing this.
 

Half the men who have never had a HIV test are convinced they don’t have HIV – but we know for sure some men are wrong about this. Most untested men think they probably don’t have HIV but some are not sure, and a few haven’t tested yet, even though they think they probably have HIV.
 

I Did It campaign

A national testing campaign is now running across England using outdoor, online and gay press adverts. The I Did It campaign believes men are more likely to take a HIV test if they hear positive things from other men about testing, whatever the result.

There's a new website to inspire and encourage men through hearing other men’s test stories. It has a handy local clinic finder, and men can come back and tell their own HIV test story.

Clips of positive men talking
Aside from men’s HIV test stories and the clinic finder, the website has key facts about HIV tests, a discussion forum for men to talk about testing, videos of positive men talking about receiving a positive test result, and information on the support available for men who test HIV positive.

G.A.Y. founder Jeremy Joseph has just taken a HIV test and talks about his own test result in PinkNews

Testing information and clinic finder THIVK - Test, Take Control

I Did It

The full European Sex Survey report will be out In September 2011. You can find more about the survey here

And the results are published here

UK reports dealing with HIV testing among gay and bi men:

Tactical Dangers – report of UK’s Gay Men’s Sex Survey 2008

Testing Targets – report of UK’s Gay Men’s Sex Survey 2007

Disadvantage Affects HIV Futures

posted: 25/01/2011

Low incomes and social disadvantage strikingly affects the life and health prospects of people newly diagnosed with HIV, according to a multi-national study.

An international team wanted to find out if sex and ethnicity affect the outcomes people can expect from their HIV treatment and care. The study looked at people in Australia, Brazil, Canada and the US, and found that sex and ethnicity make often striking differences in health prospects for women and men, and for ethnic minority people compared with white people.
 

Lesson - deal with disadvantages

The lesson the study teaches us “is that socioeconomic factors are a critical influence in determining the likelihood of engaging patients in care. As a result, these factors cannot be overlooked when developing programs that aim to increase the percentage of HIV-infected patients on therapy with undetectable viremia [Viral Load].”
 

The editorial in the Journal of Infectious Diseases says that social and economic disadvantages “represent complex challenges that are beyond the traditional influence of public health,” but the failure to deal with these, undermines attempts to deal effectively with HIV.
 

UK – we have the tool but refuse to use it
In the UK, the tool in the policy toolbox that could make a real difference, the new legal socio-economic equality duty on public bodies, has been locked away by the new government. The conservative led government has decided not to implement this part of the new Equality Act.

The government has also introduced a programme of major cuts in welfare benefits, and in funding for the NHS, Councils and community sector, which will all deepen the HIV disadvantages among people in the UK that we already see.
 

Do sex and ethnicity make a difference with HIV?
The new study looked at eight years in the life of people who were diagnosed very soon after getting HIV. They found that women do worse than men, and people of ethnic minority backgrounds living in the South of the USA have the most HIV-related illnesses.
 

Even when people take HIV tests and become diagnosed, poverty and social disadvantage remain real barriers to many people attending clinics, taking treatments properly and having a reasonably healthy lifestyle.
 

This was an observational study of over 2250 people who were diagnosed with early-stage HIV between 1997 and 2007, in Australia, Brazil, Canada and the US. The people were followed for up to eight years.
 

Women and men
Only 5% of the people in the study are women and most of the women (55%) were of ethnic minority backgrounds. Women had a significantly lower Viral Load (VL) count to start with than the men, but significantly higher CD4 counts (not surprising, since women tend to have higher CD4 counts than men). Three quarters of the men were white.
 

It seems there were few women in the study because the women were half as likely as men to have symptoms typical of early HIV infection, and so women were much less likely to be diagnosed than men at this early stage of HIV.
 

Treating women and men
Similar proportions of both women and men began HIV treatment, and their CD4 cell counts matched when treatment began.
 

But women and men of ethnic minority backgrounds were less likely to start HIV treatment than white men and women. And anyone living in the southern states of the USA was significantly less likely to start HIV treatment.
 

Six months after treatment started, men and women were as likely to have their viral load fall below 400 and have similar increases in CD4 counts.
 

Untreated women and men
However, the investigators then analysed changes in the viral load and CD4 cell count of the people who did not start HIV treatment for up to three years. “Despite the fact women had higher CD4 cell counts and lower viral loads at study entry, they subsequently experienced significantly more combined HIV-related and AIDS-defining events,” emphasise the investigators.
 

Nothing to do with biology: it’s poverty and social disadvantage
After they did their detailed analysis there found no grounds for believing biology is causing women to develop HIV-related illnesses. Instead these illnesses “are the result of socioeconomic conditions.” These include “access to health care, health behaviors, lifestyle and environmental exposures.”
 

Stark ethnic treatment divide

Stark significant ethnic differences are plainly seen in the numbers of people getting HIV illnesses or an AIDS diagnosis.  Eight years after diagnosis

• almost 8 out of 10 (78%) of ethnic minority people in the Southern states of the USA got either an HIV-related illness or AIDS,
• compared to less than 4 out of 10 (37%) of white people living in the same states, and
• compared with a quarter (24%) of white people living elsewhere, and
• about two out of ten (17%) ethnic minority people living outside the South.

USA HIV strategy has three goals: cutting the number of people who are undiagnosed; getting more people to clinics and on effective treatment; and cutting HIV-related health inequalities.
 

But the editorial points out “the findings from this study threaten the success of each of these pillars.” They therefore call for “a collaborative policy and research effort across all levels of community, government and science.”
 

Source Aidsmap has references and links to two free journal articles

New Sexual Health Strategy

posted: 21/01/2011

There will, at last, be a new Sexual Health Strategy for England this year. Public Health Minister, Anne Milton, agreed it is time to replace the HIV and sexual health strategy, which was drawn up in 2001.
 

David Cairns MP, Chair of the All Party Parliamentary Group on HIV & AIDS, shamed English health ministers into action, by making an unfavourable comparison with Scotland, who have a more recent Sexual Health plan.

The All Party Parliamentary Group, and others, repeatedly pushed the Government for a new English strategy.

Finally at a debate on World AIDS Day in Westminster Hall, the Public Health Minister announced there will be a new strategy for England. Anne Milton confirmed it would be more than just a ‘position paper.’
 

“HIV has changed enormously in the last decade. It is now a long-term health condition, not a death sentence, and there are far more people now living with the virus. We’ve been arguing for a new strategy to reflect those changes and I am very pleased that the Government has decided to draw one up this year,” said David Cairns MP, chair of the All Party Parliamentary Group.
 

Remember this?

The 2001 English strategy aimed to:

• reduce the transmission of HIV and STIs
• reduce the prevalence of undiagnosed HIV and STIs
• reduce unintended pregnancy rates
• improve health and social care for people living with HIV
• reduce the stigma associated with HIV and STIs.

To do this the 2001 English Strategy said about HIV, that it would :

• provide clear information about avoiding STIs, including HIV
• increase HIV testing [testing is up]
• ensure there is a sound evidence base of what works in HIV/STI prevention
• set a target to reduce the number of new HIV infections [this target was hopelessly missed]
• develop managed networks for HIV and sexual health services [we have 3 NW networks]
• set a target to reduce the number with undiagnosed HIV [now at last, but we had to wait until 2011]
• ensure earlier access to HIV treatment [This is still a major problem, England has a high level of late HIV diagnosis]
• set standards for treatment, support and social care of people living with HIV [where are the standards for social care support? but we do have excellent standards for treatment]
• prioritise researching good practice in sexual health and HIV

On other sexual health issues the 2001 plan was to 

• evaluate more integrated sexual health services
• screen for Chlamydia
• stress open access to GUM services and more urgent appointments
• ensure a range of contraceptive services are provided
• address the patchy abortion service
• increase hepatitis B vaccinations
• set standards for treating STIs
• train and develop the sexual health workforce
   

Manchester HIV Training

posted: 19/01/2011

Dates and details of all the training courses on HIV, sexual health, drugs and alcohol for the next year are now listed and can be booked with Manchester Public Health Service.

HIV courses

• Positive Interventions : HIV & Sexual Health Awareness

2 Day course, for frontline workers, in April, July, November, January (2012), February and March

• Positive Plus : Advanced HIV Awareness

1 Day Course for frontline workers - you need to have done their HIV introduction course Back to Basics, or have a good knowledge of HIV. In May, November

• Back to Basics : An introduction to HIV and Sexual Health Awareness

1 Day Course, for frontline workers, in June, October, November, and March (2012)

• Rather have a cup of tea : Over 50’s, sexual health and HIV

1 Day Course for frontline staff working with people over 50, in August

Other Manchester sexual health, drink and drug courses

• Crushes to Hot Flushes : Women and Sexual Health (women only course)
• Getting the Measure of it : Basic alcohol awareness
• Alcohol and Dependency : Women and alcohol
• It’s a Man’s World : Working with boys and young men
• ‘It’s not an issue’ : Sexual health, sex and relationships for people with learning difficulties
• Reducing Drug Related Deaths : Overdose Management
• Living the High Life (Part 1) : Drug Awareness
• Living the High Life (Part 2) : Advanced drugs awareness
• No Girls Allowed : Men and sexual health (men only course)
• People, Pins and Prevention : Safer injection training
• The Jury’s Out : Harm Reduction
• The Sleeping Giant Awakes! : Hepatitis C
• Who ate all the P.I.E.S : ‘An Introduction to Performance and Image Enhancing Drugs’
• Call the Cops : ‘The essential guide to Legal and illegal 'Legal Highs'
• Curry & Rice : The Ultimate Take Away [about the high risks of speedballing: using heroin and crack together]

Manchester Public Health Service sexual health training booklet with application form

Sexual Health and Harm Reduction Training Administrator: Kellie McGuire
MPHDS
Mauldeth House
Mauldeth Road West
Chorlton
Manchester
M21 7RL
0161 882 2301

 

Other Manchester Public Health training booklets

• Mental Health and Well Being, contact
• Physical Activity, Health Eating & Cancer Prevention, contact
• Stop Smoking, contact

Manchester Public Health Development Service