HIV treatment as prevention
There is a lot of hope and excitement about the use of HIV treatment as prevention.
Most experts now agree that when someone with HIV is taking antiretroviral treatment as prescribed, has an undetectable viral load, and neither they nor their sexual partner has a sexually transmitted infection, they are unlikely to pass on HIV to their sexual partners. The results of a large study involving heterosexual couples showed that effective treatment reduced the risk of transmission by 96%.
Viral load is usually measured in blood and, overall, there is a relationship between viral load in blood and viral load in genital fluids.
However, in some studies, viral load in a small number of people had remained or become intermittently detectable at low levels in genital fluids, despite being suppressed in blood. This situation increases the risk of HIV transmission.
Their research involved 38 men living with HIV. Twenty-five started a standard triple-drug combination of anti-HIV drugs. The other thirteen were given an intensive combination which also included maraviroc (Celsentri) and raltegravir (Isentress). Both these drugs are very good at getting into semen and suppressing HIV replication.
Paired blood and semen samples were analysed for all the study participants over a two-year period.
The intensified combination achieved rapid suppression of viral load in semen.
The men taking intensified therapy were also less likely to have viral load blips in their semen.
However, one man taking the intensive combination had low levels of HIV detected in his semen for 14 months after starting treatment.
The researchers were concerned by this finding and looked at the records of a further 26 men taking HIV therapy to see if virus was also detectable in their semen. All had an undetectable viral load in their blood.
Approximately half of those who had been taking treatment for less than six months had virus in their semen. This fell to 20% of men who had been taking treatment for between one and three years. However, none of the men who had been taking treatment for over three years had detectable HIV in their semen.
The researchers were encouraged by the finding that viral load in semen was persistently suppressed in people taking long-term treatment.
Taking HIV treatment to reduce viral load is just one part of the picture and consistent condom use is still a key method of preventing HIV, as well as preventing other infections and unplanned pregnancy. Preventing HIV transmission is just one part of good sexual health. Find out more in our booklet HIV & sex at www.aidsmap.com/booklets.
Nevirapine side-effects during pregnancy
Nevirapine belongs to a class of anti-HIV drugs known as non-nucleoside reverse transcriptase inhibitors (NNRTIs). The commonly prescribed anti-HIV drug efavirenz (Sustiva or Stocrin, also in the combination pill Atripla) is also an NNRTI. Current World Health Organization (WHO) HIV treatment guidelines recommend use of efavirenz- or nevirapine-based combinations in low- and middle-income countries. Nevirapine is given as the preferred option in these guidelines for pregnant women. Due to the side-effects of nevirapine, British HIV Association (BHIVA) guidelines prefer that efavirenz, raltegravir, darunavir or atazanavir should be used in first-line treatment, although they say that nevirapine may be used as an alternative to these drugs.
Nevertheless, there are concerns about the safety of nevirapine during pregnancy. Researchers wanted to see if these were justified.
They therefore reviewed the results of 20 studies involving 3582 women to see if use of the drug during pregnancy increased the risk of side-effects.
Overall, 7% of women developed a liver-related side-effect, 7% developed a rash, and 7% had an allergic reaction to the drug. Treatment with nevirapine was stopped by 6% of women because of side-effects.
The researchers noted that the rates of these side-effects were high, but no higher than those seen in women who were not pregnant.
There was weak evidence suggesting that the risk of side-effects was increased for pregnant women whose CD4 cell count was above 250 cells/mm3 at the time they started nevirapine-based therapy.
However, the researchers think that the overall high rates of side-effects associated with the drug mean that, when possible, a different drug should be used.
One possibility is efavirenz. There has been a lot of debate about its safety during pregnancy. Some research suggested that it could increase the risk of birth abnormalities. However, these concerns appear to be unfounded and efavirenz can be used for the treatment of women with HIV during pregnancy.
It’s important to be open with your doctor about any concerns you have about treatment, including fears about side-effects, and to tell your doctor if you are pregnant or planning to start a family. Our Talking Points tool is designed to help you prepare for conversations with your doctor. You can try it on our website at www.aidsmap.com/talking-points.
Gay men in London and crystal meth
In January, the medical journal The Lancet published a news feature focusing on increasing use of methamphetamine (crystal meth) by gay men in London. The article expressed concern about men injecting the drug, often in the context of sex parties, and suggested that this was associated with unprotected sex, needle sharing and the possible transmission of HIV and hepatitis C.
There have long been concerns about use of crystal meth by gay men and its association with HIV risk.
In the UK, the group most likely to report use of crystal meth were gay men with HIV who have large numbers of sexual partners. However, only a very small number of men used the drug frequently.
More gay men are certainly using drug treatment services because they are concerned about their use of crystal meth. These services are also seeing an increasing number of men who report use of GBL (gamma-Butyrolactone) and mephedrone.
Surveys of gay men, conducted in 2009 and 2011, found that overall use of the drug was very low – only 0.08% reported taking crystal meth.
However, a survey of gay men’s sexual and drug use behaviours conducted in 2007 found that about 5% of respondents had taken the drug in the previous twelve months. Rates of use were higher in London, and approximately 20% of gay men living with HIV in London said they had used the drug in the previous year.
Gay men reporting use of crystal meth frequently reported the use of other drugs as well.
Crystal meth use can be incredibly destructive, and there can be little doubt that gay men have become infected with HIV and/or hepatitis C while using it.
However, it’s most likely that a number of factors – drug use included – have a role in the epidemiology of HIV and hepatitis C among gay men in London.
If you are concerned about your use of crystal meth or any other drug, help is available. Your HIV clinic is a good place to start. They won’t judge you about your drug use and will be able to offer practical advice and support and also refer you to specialists who can help. The LGBT charity London Friend runs a drug and alcohol service called Antidote – you can call them on 020 7833 1674 or find out more on their website: www.londonfriend.org.uk/get-support/drugsandalcohol
Editors' picks from other sources
Texas: Food availability linked with poor outcomes for HIV-positive children
from Baylor College of Medicine press release
An HIV-positive child whose family does not have enough good food available is more likely to have a poor clinical outcome, researchers reported. They found that children who did not always have enough to eat had lower CD4 counts as well as higher chances of incomplete viral suppression.
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 healthcare for lesbian and gay people. Although the research was conducted primarily on gay men in the US, the implications for other sexual minority groups in nations considering same-sex marriage legislation are far-reaching.
Zimbabwe: Cervical cancer a major threat to HIV-positive women
from IRIN Plus News
HIV-positive women are living longer, but are now dying of cervical cancer. In Zimbabwe, cervical cancer is now the most common cancer among women, particularly those living with HIV. Activists are urging the government to step up efforts to prevent deaths related to the disease, accusing it of paying lip service to the problem.