PrEP reduces infections in injecting drug users
This is a significant step forward for HIV prevention – PrEP has now been shown to reduce infections in several key populations – injecting drug users, men who have sex with men, heterosexual serodiscordant couples and infants (vertical transmission). However, studies with young African women have had disappointing results, because few of the women took the drug regularly.
The new study, conducted with 2413 injecting drug users in Thailand, began in 2005 and has been highly controversial. Thai activists felt that PrEP was being offered as a second-best option when the proven prevention intervention of needle exchange was unavailable.
Over seven years, participants were randomised to either receive the anti-HIV drug tenofovir (PrEP) or a placebo (dummy pill). Most individuals came into a clinic each day to receive their medication from a nurse and received a 70 baht (€1.70) financial incentive each time they did so.
Perhaps because of this, adherence and retention were relatively good for a cohort of injecting drug users. According to daily diaries, participants took the study drug on 84% of days and they stayed in the study an average of four years. As in other PrEP studies, those who took the medication most consistently had higher levels of protection.
Fifty of the 2413 participants became HIV positive during the study – 17 were in the PrEP group, and 33 were in the placebo group. This amounts to PrEP preventing half (48.9%) of new HIV infections.
Comment: Numerous aspects of this study require further examination. Perhaps due to the risk-reduction counselling and opioid substitution therapy (but not needle exchange) that the participants received, injecting drug use and needle sharing dropped dramatically while participants were in the trial. There were fewer HIV infections than the researchers expected in the control arm, and some experts believe that PrEP could have been preventing sexual transmission as much as injecting-associated transmission. The use of directly observed therapy and relatively generous financial incentives both points to an effective way to maintain adherence in this population and raises questions about the applicability of the findings in services where such support is not provided. Moreover, it is clear that PrEP should not be seen as a replacement for needle exchange, but may be included as part of a combination prevention programme alongside provision of clean needles and syringes, opioid substitution therapy, accessible healthcare services, the removal of punitive laws, and work with police and law enforcement bodies.
Best to target combination prevention to highest-risk groups
Researchers developed a mathematical model based on HIV prevalence trends in a Vietnamese province, Can Tho.
The model suggests that providing annual HIV tests to all adults, with people testing positive receiving immediate HIV therapy, would reduce the number of new infections by 80%. But this would be at the cost of tripling the budget for HIV treatment and testing.
Annual testing and immediate treatment targeted at people who inject drugs achieved results that were almost as good (75% fewer diagnoses). The estimated costs were just 7% higher than those associated with maintaining existing treatment levels and prevention coverage.
It was most efficient to target at-risk populations which are relatively small. For example, there are around 2000 female sex workers in Can Tho, but they have approximately 62,000 clients. While these men (and their other partners) are at risk, reaching them with a testing programme would add considerable costs to the programme.
The most cost-effective strategy combined a ‘test and treat’ approach for high-risk groups with methadone maintenance therapy and substantial increases in condom use.
Comment: While the headline finding from the analysis was that a combination prevention approach could “eliminate” the province’s epidemic in 15 years, the model had some utopian assumptions built into it. It was assumed that all members of a population could be reached by healthcare staff and would accept the offer of an HIV test, and that antiretroviral therapy could be provided to everybody with diagnosed HIV. Much more interesting is what the model shows about the value of correctly targeting interventions to high-risk groups who contribute a disproportionate amount to the overall epidemic. These findings from a concentrated epidemic are therefore of interest in Europe too.
European gay men crossing borders
The recently released report from the European Men Who Have Sex with Men Internet Survey (EMIS) contains a wealth of data on the behaviour and HIV prevention needs of men who have sex with men living in Europe. With over 180,000 participants from 38 European countries, this is the largest international study of men who have sex with men ever conducted.
Some of the data cover migrant gay men – in other words, men who live outside of their country of birth, who made up 12% of the sample. In Luxembourg, Cyprus, the UK and Switzerland, over a quarter of respondents were migrants. Most frequently, migrants came from nearby European countries, although some came from further afield (for example, large numbers of Latin American men in Spain and Portugal).
Migrants were 17% more likely than indigenous men to say they were HIV positive, and 21% more likely to have been recently diagnosed with a sexually transmitted infection (STI). But they were 26% more likely than non-migrant men to report difficulty accessing HIV testing, and 32% more likely to have problems accessing STI testing.
The survey also asked about men having sex abroad, while on holiday or travelling for work. A quarter of respondents had had sex abroad in the past year, most often while in Spain or Germany. Men with diagnosed HIV often reported unprotected anal intercourse – a behaviour they usually reported at home too.
These data add to the study reported in last month’s bulletin, which highlighted transmission clusters across European borders.
Comment: The higher prevalence of HIV and STIs among migrant men, and their difficulty accessing free or affordable HIV and testing services, show that interventions need to be tailored and targeted for this group. However, “migrant men” is a very broad group, including men migrating for economic reasons and others fleeing hostile social environments. Their needs and experiences are unlikely to be the same. The survey also found that men having sex abroad often met their partners via the internet, suggesting that health promotion for travellers could also be delivered online.
European gay men buying and selling sex
Most men buying or selling sex had only done so once or twice in the past year. This suggests that the term ‘sex worker’ would be inappropriate for many of those selling sex, who seem to have had mostly opportunistic exchanges.
Whereas men over the age of 40 were ten times more likely than other men to pay for sex, those under the age of 25 were eight times more likely to have been paid for it.
Men with over fifty sexual partners a year were much more likely to both buy and sell sex than other men. Several of the other associations were shared by buyers and sellers – feeling lonely, identifying as bisexual, and using illegal drugs.
In addition, those being paid for sex were more likely to be unemployed and have less education. Moreover, they were more likely to report unprotected anal intercourse, having recently had an STI, and being diagnosed with HIV.
Comment: As the researchers stress, neither buying nor selling sex automatically involves an increased risk of HIV infection. However, there are likely to be economic and relational factors which lead men to sell sex and increase their vulnerability to HIV. Both men who bought and sold sex reported multiple partners and drug use, which are associated with an increased risk of infection.
Critique of ‘community viral load’
In recent years, some researchers have suggested that increases in the uptake of HIV testing and treatment in cities like San Francisco and Vancouver have resulted in a lowering of the average viral load in those places. And they have argued that the average or ‘community’ viral load can explain recent decreases in HIV infections in those cities.
However, now experts have identified some technical problems with community viral load. The experts do not say that viral load and infectiousness are unimportant, but that they are very difficult to measure in a community. Moreover, other factors need to be considered when explaining HIV rates.
One problem is that estimates of community viral load rely on viral load results in people with diagnosed HIV who receive medical care. Undiagnosed people and people who have dropped out of care are likely to have very different viral loads.
Another problem is that the risk of an HIV-negative person acquiring HIV from a new sexual partner depends not only on the average infectiousness of a person with HIV, but also on the likelihood that a new partner has HIV at all. In other words, prevalence needs to be taken into account.
Comment: The authors propose an alternative measure, which they say would more accurately reflect infectious HIV in a community. They recommend calculating the proportion of people who have detectable HIV in the whole population (i.e. both HIV-negative and HIV-positive people). Individuals with undiagnosed HIV would be assumed to have detectable virus. Calculating the figure would rely on having a good estimate of the number of people with undiagnosed HIV.
European HIV prevention webinars – next-generation condoms
As part of its European HIV prevention work, NAM is collaborating with AVAC to provide a series of webinars (conference calls with accompanying slides) to train and inform prevention advocates and anyone interested in the newest developments in HIV prevention technology.
The sixth webinar is entitled:
Next-generation condoms: European research and perspectives
This webinar will focus on the next generation of male and female condoms being introduced to meet specific HIV prevention needs.
Time and date: 2pm UK time (BST), Tuesday 23 July (3pm CEST)
To register for the webinar and get phone numbers and joining instructions click this link:
https://cc.readytalk.com/cc/s/registrations/new?cid=ozflmhnrw3zl
As usual, the presentations will be followed by a question and answer session with our expert speakers. Questions can be submitted in advance to info@avac.org. The webinar will be 90 minutes long and chaired by Rebekah Webb of AVAC.
Other recent news headlines
Deciding what’s risky – Australian gay men pay more attention to the sexual act than to their partner’s HIV status or viral load
HIV-negative gay men in Sydney, Australia perceive the risk of HIV transmission to be different in different sexual contexts, according to a study by Dr Limin Mao and colleagues, reported in the May issue of AIDS & Behavior. But men pay considerably more attention to condom use, withdrawal and sexual role than they do to their partner’s reported HIV status or viral load in assessing the risk of transmission.
Female sex workers frequently offered larger fees by their clients in return for sex without a condom
Client demand for unprotected sex is contributing to the HIV epidemic among female sex workers, according to Canadian research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Investigators in Vancouver found that approximately three-quarters of sex workers were offered more money by clients for sex without a condom and that 19% accepted this money. Transgender women were more likely to accept extra money for unsafe sex, as were women who experienced client violence and users of methamphetamine.
Dramatic improvements in HIV testing are possible – local leadership and multiple initiatives required
In Brighton & Hove the proportion of new HIV diagnoses which are made outside of sexual health and antenatal clinics has increased from 25.7% in 2000 to 57.8% in 2012, driven by improvements in HIV testing in primary care and community settings. Moreover, there has been a dramatic improvement in the diagnosis of recent HIV infection.
Majority of Italian HIV specialists would prescribe PrEP
Seventy per cent of Italian HIV specialists who answered an online survey would prescribe pre-exposure prophylaxis (PrEP) to people in their care who ask for it, at least in some circumstances, a study has found.
Editors' picks from other sources
HIV in Europe
International health organisations have issued a series of reports on HIV in Europe in the past month.
The World Bank, the World Health Organization and the London School of Hygiene and Tropical Medicine issued a report concluding that social and structural factors – such as poverty, marginalization and stigma – and not just individual behaviours are driving the HIV epidemic in Europe and central Asia. The report says that successful HIV prevention requires social and environmental change – barriers to HIV responses include the criminalisation of sex work, of sex between men, and of drug use, combined with social stigmatisation, violence and rights violations.
The European Centre for Disease Prevention and Control (ECDC) issued a series of reports on how European governments have responded to HIV, covering policies and funding for antiretroviral treatment and HIV prevention, especially for key populations. The ECDC also issued a report describing and evaluating partner notification policies and practices across Europe and a report on monitoring recent HIV infections.
The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) issued its annual drug report, noting record levels of treatment provision and some signs of erosion in injecting.
Russia passes bill banning gay 'propaganda'
from Wall Street Journal
Russia's lower house of Parliament passed a bill this month that bans "propaganda of non-traditional sexual relations," makes it a crime to hold gay pride events, speak in defence of gay rights or to say gay relationships are equal to heterosexual ones. Although ostensibly intended to protect minors, the bill is written so broadly that in effect it amounts to an outright ban.
Next steps for PrEP: getting a proven prevention option to the people who need it
from GMHC Treatment Issues
Men and women need new prevention options that they can – and want – to use. For some people, that is a daily oral pill. But PrEP trials have taught us that biomedical tools have to work within the complex realities of people’s lives. The challenge is finding that marriage of need and desire to suit men’s and women’s lives, and then providing access to the right products at the right time.
Moving beyond that-which-must-not-be-named: alternatives to syringe exchange
from Huffington Post
In the face of resistance to syringe exchange programmes, some states might want to steer clear of that-which-must-not-be-named and consider alternative means to syringe access and disease reduction, such as changes in syringe acquisition, enforcement, and disposal.