You may have an undetectable viral load, but your partner may still need PrEP or PEP

New HIV infections among the HIV-negative gay men in the PARTNER study, due to sex with partners outside the main relationship, was high, a recent conference heard.

PARTNER made headlines by demonstrating that there were no transmissions from an HIV-positive partner who was on antiretroviral therapy and virally suppressed in almost 60,000 acts of condomless sex. These data allowed the researchers to establish the maximum possible likelihood of transmission, and to announce that, most likely, the chance of an HIV-positive partner with a fully suppressed viral load of below 200 copies/ml passing on HIV was zero. PARTNER provides crucial evidence for the U=U (Undetectable = Untransmittable) campaign.

However, there were HIV infections in PARTNER: eleven of them by 2016, ten in gay men. In all cases, however, phylogenetic testing showed that the infecting virus came from someone other than the primary partner.

Each year, 2% of HIV-negative gay male partners acquired HIV. Looking only at those men who reported having condomless anal sex with non-primary partners, each year 7% acquired HIV.

In short, men whose main partner is undetectable are not safe from HIV if they are also having condomless sex with other people. In this situation, it would make sense for the HIV-negative man to use post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP).

But very few of those taking part in the PARTNER study did so, resulting in these high levels of infection.

To find out more, read NAM’s factsheets on PrEP, PEP and viral load.

HPV and anal cancer

HPV (human papillomavirus) is a sexually transmitted virus that causes genital warts, and in some forms, leads to the development of cervical, anal, mouth and throat cancers. Anal cancer, rare in the general population, is becoming more common in people living with HIV, especially men who have sex with men.

The European AIDS Clinical Society has strengthened its advice on vaccination against HPV. All people living with HIV under the age of 26 and all gay men living with HIV under the age of 40 should be vaccinated, it says. These recommendations are in line with the guidance of the British HIV Association (BHIVA).

The reason why these guidelines include upper age limits is that the older you are, the more likely it is that you have already been exposed to several types of HPV, making the vaccine less effective. The younger you are, the more likely you are to benefit from vaccination.

Recently, Dutch clinicians reported on their experience of screening gay men living with HIV for pre-cancerous anal lesions. This is not the same as anal cancer, but having these pre-cancerous cell changes is associated with a small risk of developing cancer in the future. The lesions might go away on their own, but in case they don’t, many doctors would recommend treatment. 

Of just under 1700 men who were screened, they found that 30% had high-grade lesions. Given this high rate, the clinicians believe that screening all gay men living with HIV would be a good idea.

Nonetheless, screening for pre-cancerous anal cell changes in people who don’t have symptoms is not currently recommended in guidelines. This is because we don’t yet know whether the available treatments are good enough to make screening worthwhile in people who haven’t got symptoms. The treatments can be uncomfortable, have side-effects and don’t always stop high-grade lesions from recurring. It could be worrying to find out that you have pre-cancerous lesions, but if you didn’t know you had them, it’s possible that they would go away on their own or cause you no harm.

On the other hand, some experts believe that finding and treating high-grade lesions promptly will prevent cases of anal cancer that would be much harder to treat later on, so they think it is worth getting tested regularly.

These doctors also point to high rates of anal cancer in gay men living with HIV, for example a recent analysis from Austria – in men under 50 years, 8 in 1000 had ever had anal cancer; in men over 50 years, 26 in 1000 had ever had it. As the risk of cancer increases the older we get and more people with HIV are going to live longer in future years, these rates could increase further as time goes on.

For more information, read NAM’s factsheet ‘Anal cancer and HIV’.

Does U=U apply to breastfeeding?

Taking effective HIV treatment and having an undetectable viral load massively reduces the risk of onward transmission during breastfeeding, but it does not appear that the risk is zero, a leading paediatrician from St Mary's Hospital, London said last week. Dr Hermione Lyall said that she often needed to advise women who were doing well on HIV treatment, with an undetectable viral load, who wished to breastfeed.

Studies from African countries suggest that for women with HIV taking treatment (not necessarily undetectable), around 1 to 2 in 100 may pass on HIV to their baby. More reassuringly, a recent Tanzanian study found that among 177 mothers, there were no transmissions from mothers with undetectable viral loads. This suggests that there is a very low risk of breastfeeding transmission when viral load is suppressed, but these are not enough data to say that the statement “undetectable = untransmittable” (U=U) applies to breastfeeding as well as to sexual transmission.

Dr Lyall says that women with HIV should be advised that formula feeding has a zero risk of HIV transmission and is the safest thing to do. Nonetheless, some women will choose to breastfeed and healthcare professionals should support them to do so as safely as possible.

Mothers should be advised that having an undetectable viral load, taking all their doses of their treatment and limiting the duration of breastfeeding will help lower the risk of passing HIV on. They should attend monthly check-ups with their clinical teams.

Dr Lyall also presented three key safety points that women should remember while they breastfeed:

• No virus: Only breastfeed if your HIV is undetectable.
• Happy tums: Only breastfeed if both you and your baby are free from tummy problems.
• Healthy breasts for mums: Only breastfeed if your breasts and nipples are healthy with no signs of injury or infection.

For more information, read 'After your baby is born' in NAM’s booklet ‘HIV & women’.

Healthcare workers living with HIV

Nurses and other healthcare workers who are living with HIV have mixed reactions when they mention their HIV status to colleagues, according to a small Dutch study. Some healthcare workers disclosed because they were confident they would have a positive reaction or because concealment was stressful. Very often, those disclosed to saw the participant’s HIV status as a non-issue, as one interviewee explained:

“In the beginning, it was talked about and thought about a lot but that was, at a given moment, gone and nobody gave it anymore thought.”

Other interviewees concealed because they did not believe that disclosure was relevant or necessary. Some people did not discuss their HIV status because they expected negative reactions or stigma, often because they had previously experienced this themselves or had seen it occur in relation to other people.

“I’m not going to tell them anymore because I’m, yeah, I’m scared of how my colleagues will react. And where does this come from? It comes from, for example, the fact that whenever a patient is admitted and he has HIV, then they immediately say, ‘You need to be careful, eh? He has HIV so be extra careful’.”

The researchers say that it’s important to emphasise that disclosure is a choice. Before disclosing at work, people should think carefully about their motivations for disclosure and the potential reactions they might have. The authors comment that while disclosure can be a good idea if it results in social support or less stress, it may sometimes be better to conceal at work, especially when the risks are great and social support is available elsewhere.

For more information, read 'Deciding whether to tell people that you have HIV' in NAM’s booklet ‘HIV, stigma & discrimination’.

Heart disease and kidney disease

Cardiovascular disease (angina, heart failure, stroke, blocked arteries etc) goes hand in hand with chronic kidney disease, according to an analysis of over 27,000 people living with HIV.

People who were assessed as being at high risk of cardiovascular disease were also more likely to go on to have kidney disease. Similarly, being at high risk of kidney disease increased people’s risk of having cardiovascular disease. Rates of subsequent disease were especially high in people who had been assessed as being at risk of both.

The researchers say that doctors should assess the risk of these conditions together. They should also focus on encouraging people with HIV to make lifestyle changes which lower the risk of both conditions – eat a healthy, balanced diet; exercise regularly; lose weight if you're overweight; don’t smoke; and limit your intake of drugs and alcohol.

To find out more, read NAM’s factsheets ‘The heart’ and ‘Chronic kidney disease and HIV’.