HIV update - 5th January 2017

Large drop in HIV diagnoses in London gay men

Four sexual health clinics serving large numbers of gay men in London have reported that they diagnosed far fewer gay men with HIV during 2016 than they did during 2015. These are preliminary figures and have not been fully analysed, but many doctors believe that the use of pre-exposure prophylaxis (PrEP) is part of the explanation for these reductions.

Such large drops in new diagnoses are unprecedented. 56 Dean Street had 40% fewer diagnoses overall, the Mortimer Market Centre 50% fewer, Homerton Sexual Health 40% fewer in gay men, and Barts Sexual Health Centre 36% fewer diagnoses in gay men.

On their Facebook page, 56 Dean Street summed up the factors which they believe may have contributed to the fall: “Condoms, PrEP, early diagnosis, immediate treatment.” They noted that they were testing as many people as the previous year and that rates of other sexually transmitted infections were as high as ever. Getting people who have HIV diagnosed and on to treatment as quickly as possible is probably part of the explanation – but clinics have been working towards this goal for several years already.

What appears to be new in 2016 is individuals importing PrEP medication from abroad and getting support on using PrEP safely. Dr Mags Portman of the Mortimer Market Centre said: "We made a decision to actively support those buying PrEP online early in 2016. This approach has been embraced by all staff from nurses to health advisors to doctors. We ensure that our patients at higher risk of HIV are fully informed about the use of PrEP and have access to safe monitoring alongside good sexual health advice and regular STI screening.”

The number of men taking PrEP may only be a few hundred or a few thousand, but these men may be key to slowing the epidemic. “The important thing is whether awareness and usage of PrEP is reaching the right people,” commented Dr Alan McOwan of 56 Dean Street. “If the ‘nodal’ gay men who have a lot of partners and who would have previously been at the centre of a cluster of infections are now not becoming infected, they are not passing it on to anyone else.”

For more information on PrEP, read NAM’s factsheets ‘Pre-exposure prophylaxis (PrEP)’ and ‘How to get PrEP in the UK’.

Hepatitis C virus often found in rectal fluid

Our understanding of how hepatitis C can be passed on during sex between men continues to evolve.

It has generally been thought that sexual transmission is mostly linked to sexual practices that involve some contact with blood (including tiny traces of blood you don’t notice). This makes sense as it is well known that hepatitis C is present in infectious quantities in blood. These sexual practices may include anal sex (especially when it goes on for a long time) as well as fisting and using sex toys.

But last year, American researchers reported that the virus can often be found in semen. In a group of men who had both HIV and hepatitis C, one third of the men had detectable hepatitis C in their semen. It was present in levels that were plausibly high enough to transmit the virus.

Now the same group of researchers have reported that they have also found hepatitis C in the men’s rectal fluid (in other words, secretions in the rectum). Just under half the group had detectable levels of hepatitis C in their rectal fluid. Men with higher hepatitis C viral loads in their blood tended to have higher levels in their rectal fluid.

This means that blood is not required for hepatitis C to be passed on. During anal sex without a condom, hepatitis C can be transmitted. If the insertive partner (the top) has hepatitis C, it may be present in his semen, so he could pass the infection on to the other man. Or if the receptive partner (the bottom) has hepatitis C, it could be present in his rectal fluid, so he could pass the infection on.

The researchers say that health organisations need to update the information they provide on hepatitis C. Educational resources and campaigns need to reflect what we now know about how hepatitis C is transmitted. In line with this, NAM has just updated its illustrated leaflet, ‘How hepatitis C is passed on during sex’.

More medical conditions in people living with HIV as they get older

People living with HIV are increasingly experiencing a range of medical conditions and co-morbidities as they get older, according to a large American study.

Thanks to effective HIV treatment, more HIV-positive people are surviving to older ages. But they may be at higher risk of developing a range of health problems. This may be because of lifestyle factors and the immune system’s response to HIV, but there is scientific debate about the precise causes.

The American researchers looked at data on 37,000 people living with HIV, comparing each individual with up to three HIV-negative people who they were matched with, based on their age, sex, ethnicity and type of health coverage. Just over half the participants had commercial health insurance (typically the healthiest people in the United States, with the best access to healthcare) while the others were covered by Medicaid (a programme for people on low incomes, who may have had problems accessing healthcare in the past).

Data were included from 2003 to 2013. The average age of people living with HIV increased during this period – as did the number of people with additional medical conditions.

People living with HIV had more medical conditions than HIV-negative people. People on Medicaid generally had more health problems than those with commercial coverage.

For example, amongst those with commercial insurance, 7% of HIV-positive people and 4% of HIV-negative people had heart disease. The figures for those covered by Medicaid were 11% and 8% respectively.

Figures were also high for kidney disease – amongst those with commercial insurance, 9% of HIV-positive people, compared with 3% of HIV-negative people. They were also elevated for osteoporosis (brittle bones) and fractures.

But rates of some health conditions were no higher in HIV-positive than HIV-negative people. And these were the most common health conditions – high blood pressure (31% of HIV-positive people with commercial insurance), raised cholesterol or triglycerides (31% of HIV-positive people with commercial insurance), diabetes and other endocrine disorders (21% of HIV-positive people with commercial insurance). Rates were similar in HIV-negative people.

A separate study, comparing people with HIV and people with HIV/hepatitis C co-infection, found that people in the second group were more likely to have kidney disease and osteoporosis. People who had hepatitis C that had not been brought under control by treatment had higher rates of diabetes. But it’s unclear whether these raised rates are due to the impact of hepatitis C or due to lifestyle factors – for example, people who had hepatitis C were more likely to inject drugs, drink heavily and smoke.