UK statement: treatment "as effective as condoms" in reducing HIV transmission
The UK’s Expert Advisory Group on AIDS (EAGA) and the British HIV Association (BHIVA) has published a position statement on the use of HIV treatment to reduce the risk of transmission. For the first time, the document provides UK health professionals with a consensus statement that can be used to guide discussions with individuals.
Noting that in the HPTN 052 study, the HIV-positive partner in a positive/negative (serodiscordant) couple was 96% less likely to transmit HIV if they were on antiretroviral therapy (ART), they say: “The observed reduction in HIV transmission in [this] clinical trial demonstrates that successful ART use by the person who is HIV positive is as effective as consistent condom use in limiting viral transmission”.
There has never been a randomised controlled trial of the efficacy of condom use. However, meta-analyses of observational studies of serodiscordant couples who reported 100% condom use have found the strategy to be about 80% effective in reducing HIV infection.
The statement adds that, unlike ART, condoms can prevent other sexually transmitted infections.
The document states that the risk of transmitting HIV during vaginal intercourse is “extremely low”, provided that the person with HIV is on ART and has had a sustained viral load below 50 copies/ml for more than six months, that there are no sexually transmitted infections in either partner and that viral load testing occurs every three to four months.
The statement notes that data are not available for anal intercourse or for transmission via needles but says: “It is expert opinion that an extremely low risk of transmission can also be anticipated for these practices, provided the same conditions stated above are met”.
It adds that healthcare professionals should discuss the impact of ART on sexual transmission with all people living with HIV. For people not currently on therapy, the possibility of starting treatment in order to reduce transmission risk should be discussed.
Comment: The current BHIVA treatment guidelines already recommend that HIV doctors discuss the effectiveness of ART as HIV prevention with all their patients. The importance of this statement is that it is co-written with EAGA, which was set up in 1985 “To provide advice on such matters relating to HIV/AIDS as may be referred to it by the Chief Medical Officers of the Health Departments of the United Kingdom”. EAGA consists of HIV physicians, other medical experts, and lay members and the authors of the statement include representatives from BHIVA, NAT, MEDFASH, NAM and the Department of Health. This advisory document aims to help doctors and patients talk about the use of ART as prevention, but also to provide evidence to make the case for the provision of resources to support its use.
Condoms used in a quarter of heterosexual encounters in the US
One-in-four heterosexual adults in the United States used a condom the last time they had vaginal sex, researchers from Indiana University have found. Most people reported that condom use made no difference to sexual pleasure, to orgasm, or, in men, to maintaining an erection.
However, men reported a small but statistically significant reduction in sexual pleasure when they used condoms without also using an extra lubricant, and women reported more difficulty in achieving vaginal wetness.
Neither condom nor lubricant use affected whether partners had an orgasm, or whether they perceived that their partner did. There were interesting gender differences, though: while 95% of men had an orgasm and 94% of women perceived that they did, only 66% of women had an orgasm – although men thought they did 90% of the time.
Condoms were used by 27.5% of men and 22% of women the last time they had sex. Of those who did not use a condom, 25% of men (18% of all men) and 29% of women (22.5% of all women) used a sexual lubricant, while only 5% of men and women reported using both a condom and extra lubricant.
This left 61% of men and women who used neither condom nor lubricant.
Eighty per cent of lubricants used were water- or silicone-based. Only four men and two women reported using oil-based products with condoms, but in all cases these were latex condoms, which would be weakened by the lubricant.
Comment: This was not a study of couples, but individual men and women. As a result condom use cannot be related to what kind of partner participants were having sex with, although condom use approximately matches the proportion of casual/new partners. While 25% of heterosexual people used condoms last time they had vaginal sex, in the matching gay men’s survey, 45% of gay men reported using a condom last time they had anal sex. It is encouraging to note that, in this survey at least, condoms were reported as only very slightly affecting sexual pleasure and that using oil-based lubricants with them was rare.
HIV infections in gay men unchanged or increasing in England and Wales, despite more testing
The number of gay men in England and Wales who become infected with HIV each year has remained unchanged between 2001 and 2010, according to a paper by the UK Medical Research Council and the Health Protection Agency (HPA). This is despite a considerable increase in testing and, they estimate, a 40% reduction in the proportion of gay men with HIV who are unaware of their status.
The number of HIV diagnoses in gay men increased from about 1800 in 2001 to 2600 in 2010. Some of this increase is due to increased testing, however, and by adjusting this for the likely length of infection, as estimated by CD4 count at diagnosis, the researchers estimated that the true annual total of HIV infections in gay men has scarcely increased, from 2200 in 2001 to about 2300 in 2010.
The number of HIV tests taken by gay men in sexual health clinics has grown nearly fourfold, from 16,000 in 2001 to 59,300 in 2010. As a result, the estimated time between infection and diagnosis has shrunk from four years to 3.2 years during this time, and the proportion of gay men with HIV who are undiagnosed from 37 to 22%.
The reason it has not shrunk more, say the authors, is due to gay men not testing often enough. Last year, the HPA reported that only an estimated 10 to 15% of gay men took an HIV test every year, and that two-thirds of gay men who tested at a clinic had, two years later, not returned to that clinic for another test.
The total number of gay men with HIV who are undiagnosed in England and Wales was estimated as 7690 in 2010.
A second paper published shortly afterwards and including some of the same authors tested the assumptions used to estimate HIV incidence in the first paper. They concluded that, based on the observed number of diagnoses, HIV incidence in gay men may in fact have risen from 0.3% a year in the 1990s to 0.53% in the last five years.
Comment: The UK has a high proportion of people diagnosed with HIV in care, on ART, and undetectable, and very low patient dropout rates. As a result 53% of all people with HIV (including the undiagnosed) are on ART with an undetectable viral load, as opposed to 28% in the US. But 22% of gay men with HIV remain undiagnosed in the UK as opposed to 14% in Vancouver and only 6% in San Francisco – and maybe half HIV infections in gay men come from the undiagnosed and recently infected. Increases in testing in gay men are not yet bringing down new infections and it is clearly time for a campaign to get gay men, especially, to test more regularly.
No HIV infections from partners on treatment in Ugandan couples
A long-term study of heterosexual couples in Uganda has found more evidence that antiretroviral therapy (ART) can curb HIV infection within the community. The study found 119 new HIV infections in 2334 couples over the course of the study, and 62 infections among the 254 couples that initially or at some point had differing HIV status. But it did not find a single example of transmission from a partner who was on antiretroviral therapy.
The study, conducted between 1989 and 2007, also found that the rate of HIV infection between couples declined during this time and that transmission likelihood was related to the HIV-positive partner’s viral load.
In 2011, the HPTN 052 study found that the HIV-positive partner in a positive/negative couple was at least 20 times less likely to transmit HIV if they were on ART than if untreated. This result, however, was achieved within the highly controlled environment of a randomised scientific trial, and we need more data on whether ART is significantly reducing the risk of transmission in ‘real world’ settings.
Compared to people with viral loads under 10,000 copies/ml, people with viral loads between 10,000 and 50,000 copies/ml were over twice as likely to transmit HIV and people with viral loads over 50,000 copies/ml nearly six times as likely. However, because viral load results were only available for a minority of participants, this effect also did not reach statistical significance.
During the study period, some of the HIV-positive partners started ART. None of them transmitted HIV, compared with 62 transmissions from HIV-positive people not on ART (transmission rate 7.35% a year). This difference was highly significant.
Comment: The important point about this study is that it was conducted in the community, not in a highly monitored setting. It adds to the weight of evidence that ART is reducing HIV transmissions, but we’ll need several more years of data for the findings to become really convincing. One point worth noting is that in this study 44% of new infections did not occur between the serodiscordant couples. In HPTN 052, which DNA-tested everyone’s HIV, 28% of infections ‘in couples’ were in fact acquired from someone else, and a recent study in the Lancet estimated that, in stable couples in Africa, 30% of all new HIV infections in men and 10% in women were due to sex outside the relationship.
Circumcision makes no difference to HIV infection in UK gay men
There has been an ongoing debate about whether circumcision might protect gay men who take the top role in anal sex. A couple of studies have reported that it is protective but more have not.
Over 17,000 men responded to the MESH survey and, of nearly 5000 who said they had unprotected sex and disclosed their HIV status, 1521 (31%) reported that they mainly (20%) or exclusively (11%) took the insertive role. Of these men, one in six was circumcised.
Of these 1521 men, 1097 had taken an HIV test. Ninety-seven men (8.8%) reported that they had HIV and there was no difference in HIV prevalence between circumcised (8.6%) and uncircumcised (8.9%) men.
Being exclusively, as opposed to mainly, top was highly protective against HIV, as other studies have found: 5% of exclusively insertive men were HIV positive as opposed to 11% mainly insertive men – a 58% reduction in HIV risk. A previous study has shown that being an exclusive top confers an 89% reduced rate of HIV versus all other sex roles.
Even in exclusively insertive men, though, there was no difference in HIV status between circumcised (5.3%) and uncircumcised (4.9%) men. Taking other factors into account, circumcised men who were exclusive tops were 16% less likely to have HIV but this is likely to be a chance finding and there is certainly nothing approaching the 60 to 70% reductions in HIV risk seen in randomised controlled trials of circumcision as HIV prevention for heterosexual men in Africa.
Comment: This study, with a reasonably large sample, strongly suggests that circumcision would not be an effective HIV prevention strategy for gay men in general, regardless of their preferred sex role. It does beg the question of why circumcision did not protect gay men who always took the insertive role. It’s unlikely to be because participants did not tell the truth about their sex role because the proportions reporting being top, bottom and versatile were the same as those seen in other surveys. Circumcision may not be protective in anal sex, or what gay men do now may not be a good guide to what they were doing at the time they caught HIV.
European HIV prevention webinars – microbicides
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 second webinar is entitled:
Microbicides research in Europe and beyond
This 90-minute webinar will examine the current state of research into topical microbicides – gels, lubes and devices that can be used to prevent HIV transmission during sex. It will provide advocates with an overview of global and European topical microbicide research. The presentations will be followed by a question and answer session with our expert speakers. The webinar will be conducted in English.
Time and date: 2pm UK time (GMT), Tuesday 26 February (3pm CET)
To register for the webinar and get phone numbers and joining instructions click this link: https://cc.readytalk.com/cc/s/registrations/new?cid=nhmm1k9bdrm6
The webinar will feature presentations by:
Dr Sheena McCormack – Overview of topical microbicide research
Dr Sheena McCormack is Senior Clinical Scientist at the Clinical Trials Unit of the UK Medical Research Council. She is Principal Investigator of the Microbicides Development Programme, which ran the MDP 301 Phase III microbicide trial in four countries in sub-Saharan Africa, and of the recently started PROUD trial of Truvada pre-exposure prophylaxis in UK gay men.
Dr Charles Kelly – outstanding research from the CHAARM microbicides research consortium
Dr Charles Kelly of King’s College, London is co-ordinator of the Combined Highly Active Anti-Retroviral Microbicides (CHAARM) programme, a collaborative project co-funded by the European Union under the 7th Framework Programme (FP7) for Research and Technological Development. CHAARM is a consortium of 31 partners representing 9 different countries in Europe including Ukraine, as well as South Africa and the US, with a €12m budget.
Jeremy Nuttall – Update on IPM’s pipeline: the dapivirine ring and beyond
Jeremy Nuttall is the Senior Director of Preclinical Sciences and Product Development for the International Partnership for Microbicides (IPM), where he is responsible for the preclinical testing of candidate microbicides and has broader product development responsibilities. Jeremy joined IPM in 2003 and has over 25 years of experience in drug development. Prior to IPM he worked as a toxicologist in contract research organisations and spent over 8 years in regulatory affairs at GlaxoSmithKline.
Harriet Langanke – Community advocacy for microbicides in Europe
Harriet Langanke is founder and director of GSSG: Gemeinnützige Stiftung Sexualität und Gesundheit, the German Foundation Sexuality and Health. She is a journalist working in the field of HIV and sexual health since 1991; she is also one of the co-founders of Germany’s national network women and AIDS which celebrated its 20th anniversary last year. As an expert for HIV and STI prevention she works primarily for and with women.
The discussion will be introduced and moderated by Gus Cairns. Gus is a writer at NAM, where he edits HIV treatment update and Preventing HIV. He also edits this HIV prevention news: Europe bulletin as part of NAM’s programme of European prevention advocacy. He is a member of the European AIDS Treatment Group, co-chair of the Steering Committee of the PROUD PrEP trial, and a member of the steering committee of the Global Forum for MSM and HIV.
European advocates interested in learning more about microbicides, and the role that Europe is playing in microbicide research, are encouraged to join this webinar and to email questions in advance to info@nam.org.uk. During the event, participants will be encouraged to ask questions via telephone.
To register for the webinar and get phone numbers and joining instructions click this link: https://cc.readytalk.com/cc/s/registrations/new?cid=nhmm1k9bdrm6
The following webinar, scheduled for 26 March, will examine the latest data on HIV treatment as prevention.
Other recent news headlines
African epidemic could be driven by higher viral loads
US researchers have found that the average HIV viral load in people not taking HIV treatment in Africa is two to five times higher than the viral loads of untreated patients in the US and Europe. The researchers estimated that if viral loads in Africa had been the same as those in the US, there would have been 14% fewer infections in general and 25% fewer in low-risk heterosexuals. They attribute the higher viral loads to a higher proportion of untreated sexually transmitted infections.
Acute HIV infection campaign had limited impact
A campaign that aimed to raise awareness among gay men in Seattle, Washington, of the symptoms of acute HIV infection was only recalled by a quarter of the target audience and had no impact on gay men’s knowledge or testing behaviour. The ‘ru2hot?’ campaign listed the symptoms of acute infection (especially fever) and encouraged men with symptoms to get tested. But there were only 1164 unique visitors to the site during a two-year period for a spend of $19,038 over three years. The efficacy of media campaigns to alert people to HIV is rarely measured and this study, the researchers comment, warns that it should be evaluated more often.
More sexual transmission of hepatitis C in US HIV-positive gay men
US researchers have found a high incidence of hepatitis C (HCV) infection among gay men with HIV. Annual incidence at the Fenway HIV clinic in Boston was 1.6% – about one new HCV infection a year in 60 men. In the study, 1059 out of 1160 clinic attendees was tested for HCV and 6% were found to have it. But only 379 had a repeat test over the next few years, and among them, another 6% tested positive. The authors conclude that HIV-positive gay men should be tested annually for hepatitis C.
Crystal meth use ‘increasing’ in London gay men
The medical journal The Lancet has published a news feature describing increasing use of methamphetamine among London gay men and an increasing number who inject it. Data from Antidote, a drug and alcohol project working with lesbian, gay, bisexual and transgender people in London shows that in 2006, just 5 of its 249 service users (2%) presented with methamphetamine use as their main problem while in 2010, 187 of 553 service users (34%) had meth as their main problem, with a further 78 people (14%) reporting its use in addition to another substance they had difficulties with.
Editors' picks from other sources
What's new in the US guidelines?
from AIDSinfo
New US HIV treatment guidelines recommend that everyone diagnosed with HIV should be treated with antiretrovirals (ARVs), although they acknowledge that evidence for the benefit of treatment in people with CD4 counts over 500 is based on non-unanimous expert opinion. They also say that antiretroviral therapy (ART) is generally recommended for people with HIV for the prevention of transmission of HIV, and say that although this is also expert opinion when it comes to anything other than vaginal sex and mother-to-child transmission, it is a “strong” expert opinion, implying consensus. The guidelines add: “Patients starting ART should be willing and able to commit to treatment and understand the benefits and risks of therapy and the importance of adherence.”
IRMA issues call for lubricant research agenda
International Rectal Microbicide Advocates (IRMA) has issued a call to action demanding that the international research community investigates the safety of sexual lubricants. Studies have shown that commonly used lubricants damage the lining of the rectum and vagina, but no systematic research has been done to find out if this increases the risk of HIV infection.
Legalising gay marriage may improve health and reduce healthcare costs
from The Guardian
In the past few years, psychologists and doctors have discovered that policy changes for or against same-sex marriage can influence patterns of health care for lesbian and gay people. One study followed the mental health of lesbian, gay and bisexual (LGB) individuals living in states who voted for constitutional amendments to ban gay marriage and found that people living in states that enacted the amendments showed higher rates of psychiatric disorders.