HIV update - 12th April 2017

HIV diagnoses in London and early treatment

Starting treatment within days of an HIV diagnosis is proving acceptable to patients at one of London’s busiest sexual health clinics, so much so that the clinic has introduced a new policy of seeing people for a medical review two days after diagnosis rather than two weeks later. This change was made in response to patient demand, Gary Whitlock of the 56 Dean Street clinic told the British HIV Association (BHIVA) conference last week in Liverpool.

Treatment guidelines now recommend that everyone with HIV should start antiretroviral treatment after diagnosis, as soon as they feel ready. Some clinics have begun to offer treatment at the time of diagnosis. Concerns have been expressed that offering treatment at the time of HIV diagnosis, or very soon after, may be unacceptable to people or may feel coercive.

56 Dean Street reported 127 new HIV diagnoses between July and November 2016 (a substantial fall compared with the previous year).

Of the 127 newly diagnosed individuals, 118 came back for the medical appointment, one quarter within two days and three-quarters within 12 days. Of those, 89 began HIV treatment at that appointment.

Gary Whitlock said that he was reassured by the 29 individuals who declined, demonstrating that patients were not being bullied into rapid treatment. In the months that followed, 26 of the 29 chose to start treatment.

At the same conference, Public Health England said that the recent fall in HIV diagnoses among gay men attending clinics in central London is due to a combination of factors, not just use of PrEP (pre-exposure prophylaxis). More frequent testing by men at higher risk of HIV infection, more rapid diagnosis and treatment of sexually transmitted infections and much faster initiation of treatment were already beginning to have a big impact before use of generic PrEP began to take off, said Dr Valerie Delpech of Public Health England.

For more information, read NAM's factsheet 'Starting HIV treatment'.

To help you think about starting treatment, try NAM's questionnaire, Get set for HIV treatment. This tool provides you with a personalised factsheet on what you need to think about when starting treatment. You can discuss this with your healthcare provider.

Suicide

Men living with HIV are twice as likely to commit suicide as other men, and are most likely to do so in the first year after their diagnosis. In the first year after diagnosis, men with HIV – both heterosexual and gay – are five times more likely to commit suicide, a large survey by Public Health England has shown.

Despite the improvements in treatment since 1997, and great improvement in life expectancy, the study found that men were just as likely to commit suicide after diagnosis in 2012 as they had been in 1997. In contrast, women with HIV showed no increased risk of suicide.

While the researchers do not have data on social or behavioural factors that might explain the findings, the particularly high rate of suicide in the first year after an HIV diagnosis suggests that stigma, difficulties adapting to the diagnosis, insufficient mental health provision and a lack of support services contribute to suicide.

Hepatitis C transmission

The hepatitis C virus is transmitted in blood, in semen and in the fluid found in the mucous membrane that lines the rectum. Hepatitis C can be transmitted during sex.

Until recently prevention advice tended to focus on sexual practices which could result in trauma to the rectum (such as fisting and use of sex toys), sometimes with additional reference to behaviours commonly reported by gay men who acquire hepatitis C (such as group sex and chemsex).

However, several recent studies have identified receptive anal sex without condoms as a risk factor.

A study presented at the British HIV Association (BHIVA) conference in Liverpool last week shows that around one in five HIV-positive gay men who recently acquired hepatitis C reported anal sex without a condom as the only behaviour that could explain their infection. The study was carried out at Mortimer Market Centre in London.

Doctors at the clinic investigated how their patients were acquiring hepatitis C after noticing that several patients did not have any of the expected risk factors for hepatitis C. They looked at all 48 patients diagnosed with acute hepatitis C at the clinic between April 2015 and April 2016.

Among the HIV-positive people who acquired hepatitis C, anal sex without a condom was commonly reported (75%). Many HIV-positive people reported recognised risk factors, including injecting drug use (31%), chemsex (drug use in a sexual context, 53%) and snorting drugs (53%). Only 3% reported fisting.

However, there were 19% of HIV-positive people with acute hepatitis C whose only risk factor was sex without a condom.

Significant numbers of HIV-positive people with acute hepatitis C had sexually transmitted infections (59%) including rectal infections (28%).

The study also found that a third of people acquiring hepatitis C were gay men who did not have HIV.

Several other studies, in London and in Amsterdam, have identified cases of hepatitis C in HIV-negative gay men, especially among men using pre-exposure prophylaxis (PrEP).

Taken together, these findings suggest that men with HIV need to be aware of the risk of acquiring hepatitis C even if drug use, fisting or group sex are not a part of your sex life.

Men without HIV, especially men using PrEP and men taking part in chemsex, drug injecting or snorting of drugs, also need to be aware of the risk of acquiring hepatitis C.

Although hepatitis C can be cured by direct-acting antiviral treatment, these new drugs are not available in England and Wales for the treatment of recent (acute) infections or hepatitis C infection that is not yet causing liver damage.

For more information on how hepatitis C is passed on during sex and how to avoid it, see the illustrated leaflet in our series of leaflets, 'The basics'.

Cancers in people with HIV and hepatitis C co-infection

As a result of antiretroviral therapy (ART), many people with HIV now have a near-normal life expectancy. However, rates of serious non-HIV-related illnesses are higher among people with HIV compared to individuals in the general population. Several studies have shown that even in the context of effective ART, people with HIV have an elevated risk of several cancers not traditionally associated with HIV infection.

In high-income countries, approximately a third of people with HIV have co-infection with hepatitis C virus (HCV). This infection has been associated with an increase in liver cancer and also with certain other malignancies, including lymphoma.

Spanish researchers have looked at whether certain cancers are more common in people with co-infection. They found that non-AIDS defining cancers were more common in people with co-infection compared with either HIV or HCV alone, although the increase in risk was modest when they excluded liver cancer from the list. Hepatitis C is the main cause of liver cancer in people with co-infection. Cancers were more common in older people with co-infection.

The authors emphasise that hepatitis C treatment plays an important role in cancer prevention in people with co-infection. Regular screening for cancers is also critical.

Poppers

Poppers are used frequently by men who have sex with men during sex as a stimulant and to make anal intercourse easier. Animal models have shown poppers to cause temporary weakening of the immune system, but numerous studies have disproved claims that poppers cause immunosuppression in gay men with HIV or lead to the development of Kaposi’s sarcoma, the most common AIDS-defining cancer.

Nevertheless, concerns persist about possible cancer risks associated with frequent use of poppers, either because of immunosuppression or because they make it easier to acquire cancer-causing viruses such as human papillomavirus (HPV).

A large study of men who have sex with men with HIV and without HIV has investigated whether use of poppers is linked to the development of cancer.

The study looked at 3223 men (1563 with HIV and 1660 without) who took part in a larger cohort study between 1996 and 2010.

The study found that men without HIV in the 50-70 age group who used poppers frequently – at least once a week for a year – during the study period were more likely to develop some non-AIDS-related cancers. Only cancers with an infectious cause, such as anal cancer, non-Hodgkin lymphoma and Hodgkin lymphoma, occurred more frequently in this group. The risk grew with more frequent use over several years.

The increase in risk was not seen in men with HIV, probably because other factors such as HIV-related immune suppression have a bigger impact on the risk of cancers with an infectious cause in HIV-positive people.