NAM prevention survey: first results
The survey ran on aidsmap.com between 15 July and 4 October this year. It was targeted at people working in HIV prevention organisations in Europe, though anyone was free to participate, and was answered by 243 people, with 71% (173) answering in English. Just over half of respondents (53%) worked for an HIV prevention agency.
In the entire survey, 46% of respondents came from outside the UK and in the English-language responses, 25% of respondents did. There were a number of English-language responses from Germany and Portugal and representation from countries ranging from Ireland to Ukraine. What follows is based on analysis of the English-language responses.
HIV testing and condom provision remain the prevention resources that respondents believed need most prioritisation. When asked if there were specific services they thought should receive higher or lower prioritisation, they thought that more resources should be put into providing antiretroviral therapy (ART) for prevention purposes, and fewer, relatively, to services for drug users and prevention of mother-to-child transmission (though one respondent said “only because it is highly prioritised already”). They were also supportive of giving more resources to behaviour change programmes, socioeconomic support to people at risk, and pre-exposure prophylaxis (PrEP), although the latter two still receive a relatively low priority rating.
Respondents thought that HIV testing rates among the people they worked with were low, with a median estimate of 37.5% for the proportion of people who have ever tested. This may be lower than in actual fact, as the HIV testing figures for the UK revealed in the recent National Survey of Sexual Attitudes and Lifestyles (see next story) show.
They tended to somewhat overestimate the effectiveness of consistent condom use in preventing HIV: 57% thought condoms were at least 95% effective, whereas only 39% thought ART was this effective. One in six thought ART was no more than 50% effective, whereas no one thought condoms were less than 65% effective.
Respondents were unsure of the efficacy of PrEP – which may reflect widely different efficacy reported in studies.
People were asked if they were confident that people who needed condoms, treatment specifically for prevention purposes, post-exposure prophylaxis (PEP) or PrEP could get them in their area: the proportion who agreed they could was 88% for condoms, 57% for ART for prevention, 67% for PEP, but only 18% for PrEP. A large majority supported more widespread access to condoms and PEP and a slightly smaller majority (78%) supported more widespread access to ART for prevention. Respondents were generally supportive of access to PrEP, with 60% supporting wider access, and only one in eight (12.4%) opposed to it: but this left nearly 30% who were uncertain about it.
Comment: This is a first look at these data, and we will analyse the non-English responses in an article next month. The survey also prompted a multitude of comments from respondents, which we will analyse in a further article. The estimates for prevention-method effectiveness are interesting: people tended to quote the efficacy of perfect condom use, rather than the typical effectiveness of 100% condom use as attested by a number of reviews, whereas the estimates for ART and PrEP effectiveness appear to be more solidly based on scientific studies.
Rise in HIV testing in UK, but only a quarter of gay men test yearly
Data from three large, representative samples of the UK population over the last two decades show a significant rise in the uptake of HIV testing, especially among men who have sex with men (MSM). Nonetheless, in high-risk groups, fewer than half of those asked had taken an HIV test in the past five years, in contrast with gay men in the US (see next story).
The figures are among those published last month from the UK’s third National Survey of Sexual Attitudes and Lifestyles (Natsal). As this study recruited a large, representative sample from households throughout Great Britain, it probably gives an accurate picture of HIV testing behaviours across the population. Natsal has been conducted in 1990, 2000 and 2010. In the most recent survey, 15,162 individuals aged 16 to 74 took part, with the sample designed to matched the profile of the UK population.
Whereas under 7% of men and 11% of women had tested for HIV in 1990, 17% of men and 28% of women had in 2010. There was more HIV testing in people at higher risk of HIV. In the new Natsal findings, 56% of men and 66% of women with more than ten sexual partners in the past five years had taken an HIV test; 52% of men who’d had sex with men in the last five years; and 44 and 46% of African men and women respectively. However, this still means that only 27% of MSM had tested in the last year.
HIV infection in the UK is still uncommon and restricted largely to people with known risk factors, Natsal 2010 found. Across the whole population aged 16 to 44 years, 2 in 1000 men (0.2%) and 1 in 1000 women (0.1%) had HIV. This amounted to nine individuals, all in identifiable risk groups.
Comment:The data from Natsal provide valuable information on the extent of infection in people who don’t attend sexual health services, and have already been used to refine estimates of undiagnosed infections in the wider population. It’s interesting to compare the HIV testing figure in men who have sex with men with the US figures in the story below where two-thirds of gay men had tested for HIV in the last year – although this was not a population-wide survey but targeted urban MSM who go to gay venues.
Condomless sex increasing in US gay men
The proportion of gay men in the US who have had anal sex without a condom at least once in the past year has increased by 9 percentage points in the last six years, and the increase is greater in HIV-negative and untested men, data from the country’s Centers for Disease Control and Prevention (CDC) show. The proportion rose from 48% in 2005 to 57% in 2011. In men who were HIV negative or did not know their status, there was a 10 percentage point rise, while in men who knew they had HIV, the rise was 7 percentage points and not statistically significant. Relative to 2005, the proportion of men saying they had had condomless sex increased by 21 percentage points in HIV-negative or untested men, and by 12.5 percentage points in men living with HIV.
In men with HIV, 56% of black men and 68% of white men reported condomless sex at least once in 2011; in HIV-negative and untested men it was 49 and 58% respectively, with higher rates (62%) in Hispanic HIV-negative men.
The CDC also looked at the proportion of men who didn’t use a condom the last time they had sex and then looked at the proportion of condomless sex that was with partners of different or unknown HIV status; this was defined as risky sex. They found that the proportion of men who reported risky sex was essentially identical in HIV-negative and diagnosed HIV-positive men – 12 and 13% respectively – and that there had been a significant fall in risky sex in HIV-positive white men from 2008 to 2011, from 17 to 11%. Men with undiagnosed HIV were, perhaps not surprisingly, two to three times as likely to report having had risky sex.
The CDC also found that only 8% of gay men (in this urban sample) had never tested for HIV; and that a third of HIV-negative or untested men had tested in the last three months, 50% in the last six months, and two-thirds in the last year.
HIV prevalence in men who had never tested was 12%, while the prevalence of undiagnosed HIV was even higher in men who last tested negative but had not taken a test for over five years – 17%. Even in men who had last tested less than three months ago, however, 4% had undiagnosed HIV.
Comment: As we say above, testing rates in US gay men contrast with the UK Natsal study, though this is a targeted rather than representative survey. The finding that even in very recent testers, 4% had HIV is startling, and reinforces the idea that ‘test and treat’ may not be enough to halt ongoing HIV transmissions in gay men. Among other findings, the CDC data also show consistently higher rates of condom use in black men, despite their far higher HIV prevalence rates: another suggestion that in this group at least we may need more than condoms and testing to stop HIV.
Partner notification highly effective at finding new HIV cases
The proportion of contacts of newly diagnosed people who also had HIV was 21%, rising to 26.5% if the newly diagnosed person was their regular partner, Dr Michael Rayment of London’s Chelsea and Westminster Hospital told the 2013 BHIVA Autumn Conference in London.
A total of 3211 contacts of the 2470 newly diagnosed people were audited and it was estimated that a total of 6400 partners were actually contacted. But it was estimated that 31% of named contacts who had been at risk of HIV did not end up being informed they had been at risk and of these 422 non-informed people, a third probably had HIV.
Of those who were informed and at risk, 1399 people (52%) came in for an HIV test and, of these, one in five were found to have HIV, or one case per 10 index cases.
HIV prevalence in tested contacts did not vary greatly between types of people. However, it was somewhat higher in black African people (25%) and significantly higher (27%) in the 890 people who were the primary partner of the index case.
The proportion of at-risk partners who attended for a test was measured in this audit at three months after notification, but 93% had attended by six months after notification and 97% by one year after notification.
Comment: As Michael Rayment commented, partner notification is a highly effective strategy for detecting HIV. However – and not surprisingly – while 91% of regular partners in this audit had been contacted by three months, only 41% of ex-partners and 34% of contactable casual partners (and that omits casual partners without any means of contact). The proportion of partners contacted also varied widely, from 62 to 97%, though whether this is due to differences in guidelines or simply due to resourcing is not clear.
People off treatment contribute most transmitted drug resistance
People in the Swiss HIV Cohort Study, which includes the majority of people with HIV in the country, were matched to data on drug resistance. It was possible to identify a potential source of HIV transmission for most of the 8% of participants with transmitted drug resistance and it was found that up to 86% of these participants may have acquired HIV from a treatment-naive individual (someone who had not previously taken HIV treatment).
People with transmitted drug resistance were 50% more likely to be diagnosed during primary HIV infection. The potential source for 52% of infections involving transmitted resistance involved people with primary HIV infection compared with 31% of people who did not transmit resistant virus.
Most people (81%) with transmitted drug resistance acquired virus that was resistant to a single class of antiretrovirals, but 11% had resistance to drugs in two classes and 7% to three classes.
By using phylogenetic analysis, researchers found that two-thirds of the study population belonged to a transmission cluster consisting of one or more linked infections.
Transmitted resistance mutations could be very persistent: two long transmission chains were identified both involving HIV with the L90M mutation. This confers resistance to the protease inhibitors nelfinavir and saquinavir, which are no longer used.
Comment: Resistance acquired while taking HIV treatment is largely due to poor adherence and ‘fragile’ drugs. These factors are susceptible to individual intervention, and the proportion of people with acquired resistance is far lower now than it was in the early days of combination ART. However, this study suggests that once a resistance mutation gets into the untreated population, it can be extraordinarily persistent. This study provides one more argument for more frequent testing in risk groups and earlier treatment in people with diagnosed HIV.
HPV increases HIV risk in men – gay and straight
Human papillomavirus (HPV) is a very common virus. Some strains of HPV are associated with genital warts, and other strains are associated with cell changes that can lead to some cancers, if left untreated.
A study has found that the risk of acquiring HIV is increased in men who have HPV infections in penile tissue. Having HPV has already been shown to increase the risk of HIV acquisition for women and this would imply that the risk is similarly raised in men with anal HPV infection – but this new study shows that the risk is also raised in men with penile HPV and is therefore less specifically a raised risk for gay men (although heterosexual men get anal HPV too).
In a 30-month follow-up of the randomised controlled trial of voluntary male medical circumcision in Kisumu, Kenya, 61 men (2.4%) acquired HIV.
Penile HPV infection was present in 61% of the men who seroconverted for HIV. After controlling for potential confounders, it was found that infection with any type of HPV raised the HIV risk by 72% and infection with the high-risk cancer-causing types of HPV by 92%, though this was just short of statistical significance. Men with three or more HPV types had over three times the HIV risk compared to people who didn’t have HPV.
Vaccination against HPV, according to the researchers, might not make much difference to this specific population. Infection with HPV types 16 and 18, which are associated with several cancers and which both licensed types of HPV vaccination protect against, was comparatively rare by itself; in most cases, people were also infected with other HPV types not protected by a vaccine.
Meanwhile, in a separate study, it has been found that, for men with HIV, maintaining a viral load below 50 copies/ml and a CD4 count above 350 cells/mm3 is protective against infection with high-risk HPV types.
Comment: Although the researchers say that infection with HPV strains 16 and 18, the most common and virulent cancer-causing types, was relatively rare by itself, the vaccine now used in the UK, Gardasil, also protects against types 6 and 11, the two strains of HPV associated with genital warts. This study does add to evidence suggesting that wider HPV vaccine coverage might contribute both to protecting at-risk HIV-negative people from HIV, as well as protecting HIV-negative and HIV-positive people of both sexes from cancer.
Other recent news headlines
Increasing diversity of sexual experience in UK
There has been significant change in British people’s sexual behaviour and attitudes in recent decades, according the 2010 National Survey of Sexual Attitudes and Lifestyles (Natsal). The differences between women and men’s sexual behaviour are narrowing, many people have expanded their sexual repertoire, and there is good evidence of continuing sexual activity as people get older. One-in-forty men and one-in-thirty women report having a partner of the same sex in the previous five years.
English health chief: addressing "resurgent" gay global epidemic is urgent
There is an increasing and potentially catastrophic HIV and sexual health epidemic in gay men and men who have sex with men (MSM) in every part of the world, Professor Kevin Fenton, the National Director of Health and Wellbeing at Public Health England, told the British HIV Association autumn conference last month.
Church attendance associated with late HIV diagnosis among US MSM
Church attendance is associated with late HIV diagnosis among men who have sex with men (MSM), according to US research. A study in Alabama found that church-attending MSM were more than twice as likely to have a CD4 cell count below 200 cells/mm3 at the time of HIV diagnosis than MSM who did not attend church. There was also some evidence that church attendance was associated with less frequent HIV testing among MSM.
Largest ever number of HIV diagnoses in UK gay men
Public Health England estimates that around 2400 men who have sex with men newly acquired HIV during the year – a figure that has not changed in the past decade. During 2012, 3250 gay men were diagnosed with HIV in the United Kingdom, the largest number of cases ever recorded. The good news, however, is that the proportion of gay men living with HIV who were unaware of their infection fell from 26% in 2010 to 18% in 2012.
Editors' picks from other sources
AVAC urges HIV prevention research "Reality Check"
from AVAC
In a report released on 9 December, the HIV prevention advocacy organisation AVAC called on funders and researchers to capitalise on lessons learned from a range of recent HIV prevention trials with better problem solving, more critical thinking and co-ordinated action around large-scale human trials, faster roll-out of proven options and ongoing research for new advances that women and men will want to use.
“Raw Sex” – are the rules changing?
from BETA blog
San Francisco sexual health clinic the Magnet centre hosted a lively Real Talk discussion about condomless sex and HIV prevention on 3 December, featuring a panel of community members and experts, the forum considered questions such as: Why do gay and bisexual men have condom-free sex? Are community attitudes around condom use changing? How do treatment as prevention and pre-exposure prophylaxis (PrEP) factor into the equation?
Nelson Mandela: An interview with Zackie Achmat
from Ground Up
Interview with leading South African HIV activist Zackie Achmat about Nelson Mandela. In the 2000s, Achmat led the struggle for life-saving medicines for people with HIV. Achmat discusses Mandela's Rivonia trial speech, how he symbolised the ideal absent father and Madiba's role in the battle for AIDS treatment.
UK: Doctors 'not following' HIV guidance
from BBC Newsbeat
Medical professionals and a sexual health charity say some doctors in parts of the UK are failing to follow testing guidelines for HIV. Staff from Britain's largest NHS trust, Barts Health, say that clinicians in areas where infection rates are higher than average are not offering tests routinely, as recommended.
Cultural taboos, changing sexual norms spur HIV surge in Iran
from Al Jazeera America
Iran is facing a surge in HIV infection, according to its Health Minister Hassan Hashemi, announcing a ninefold increase in diagnoses over the past decade. This suggests a dramatic reversal in the Islamic Republic's efforts to stem the rate of HIV infection, which the country was believed to have effectively contained in 2006. Hashemi said the greatest rise in infections was through sexual contact.
Australia: Treatment as prevention, what do we think?
from NAPWA
In November last year, all the peak national HIV organisations in Australia signed onto ‘The Melbourne Declaration’ calling on government to support a range of treatment as prevention approaches. However, one year on from The Melbourne Declaration and progress is slow. There has been some success in getting governments to support the measures. In August, the federal government signed up to work towards the target of reducing HIV infections by 50% by 2015.
Rights and Wrongs
from The Lancet
Anti-criminalisation campaigner Matthew Weait reviews "Ruins", the documentary about the arrest, exposure and public vilification of a group of women as HIV risks in Greece in the run-up to the 2012 election. "Ruins" explores how a legal regulation revived by the Minister of Health, Andreas Loverdos, was used by the police to drag women from the streets on suspicion, but without proof, of being sex workers, to have them tested for HIV against their will in police stations.
How will AIDS be eradicated? – Room for Debate
from New York Times
In the war on HIV, we have seen successes in some African nations and stubborn patterns of new infection in developed nations like the US. Around the world, there are obstacles to prevention and treatment. How will they be overcome? The New York Times invited seven respondents ranging from the Director of UNAIDS to Sir Elton John to contribute to the debate.