Urgent need to improve sexual health screening for gay men in Europe
Less than one third of gay men and other men who have sex with men (MSM) in 40 European cities has been screened for sexually transmitted infections (STIs) in the past year, according to a study based on the findings of the European Men Who Have Sex with Men Internet Survey (EMIS).
Furthermore, screening for bacterial STIs such as gonorrhoea and chlamydia is only done in a minority of cities. These tests were only routinely performed in the UK, Ireland, the Netherlands and Scandinavia.
For this analysis, data were included on 52,430 respondents living in 40 large cities. Low levels of STI screening were reported by men living in several cities which have a large gay commercial scene, including Berlin, Brussels, Cologne, Barcelona, Zurich, Madrid and Paris.
Overall, 30% of respondents in the 40 cities had been screened for an STI over the last year; the proportion ranged from 9% in Istanbul to 48% in Amsterdam.
Most screenings – over 85% everywhere – involved a blood test, but these can only detect syphilis, HIV and viral hepatitis. A urine test or swab from the penis is needed to detect gonorrhoea or chlamydia in the penis, and a rectal swab is needed to detect these infections in the rectum. On average, only 49% had a urine test or penis swab and 16% a rectal swab. In contrast, services in cities in the UK, Ireland, the Netherlands and Scandinavia were more thorough and, in some Dutch and British cities, more than 88% of men attending for STI screening had a penile swab or urine test and 65% a rectal swab.
In an editorial linked to the Europe-wide study, epidemiologists from Public Health England and the Institut de Veille Sanitaire in France comment: “The provision of comprehensive sexual health screening is essential for MSM and the challenge is to establish such services in at least all the major European cities.”
Comment: One of the biggest surprises from the EMIS report was how inadequate and inconsistent STI services for gay men were in different European countries, and especially the failure of many to test for bacterial STIs. These are often asymptomatic, but even without symptoms these STIs can dramatically increase people’s vulnerability to HIV infection or, if they have HIV and are not virally suppressed, the likelihood that they will transmit it. This suggests the need for a pan-European set of standards of care for sexual health services.
Gay men who don't have anal sex still at high risk of bacterial STIs
“We found a substantial and significant risk of primary syphilis and urethral gonorrhoea for men who had not had anal sex,” comment the authors. “This risk was not different to the risk of these infections in men reporting anal sex.”
The researchers analysed the records of gay men attending the Melbourne Sexual Health Centre between 2002 and 2012. Six per cent of these men reported no recent anal sex.
Out of 204 cases of primary syphilis, 12 (6%) involved men who reported no anal sex and, in 618 cases of urethral gonorrhoea diagnosed, 44 (7.1%) reported no anal sex. There was no difference in incidence between men who did, and did not, report anal sex for either infection, and no difference in incidence between men who reported always using condoms and ones using condoms inconsistently.
However, in 673 cases of urethral chlamydia, incidence in men not reporting anal sex (at 1.2 cases per 1000 consultations), was half what it was in people reporting anal sex. Incidence was 75% higher in people who had anal sex but who always used condoms and 176% higher in people inconsistently using condoms.
“It is important than MSM are aware that sexual practices other than anal sex pose a risk of infection,” comment the investigators. They suggest that, as well as oral sex, practices such as 'nudging' (external contact between the penis and anus) and 'dipping' (insertion of the penis without ejaculation) may contribute to the spread of infection.
Comment: It is already known that up to half of syphilis in gay men is transmitted via oral sex. The gonorrhoea finding is surprising, especially as only urethral rather than pharyngeal (throat) gonorrhoea was considered. Do these gonorrhoea infections represent spread from throat to urethra during oral sex, or anal/genital contact as the researchers suggest? Urethral gonorrhoea incidence has been used in some studies as a ‘surrogate marker’ for condom use; but in this study urethral gonorrhoea incidence was not statistically higher in people who had anal sex without condoms than in people who reported no anal sex at all. This has implications for surveillance programmes and modelling as well as for sexual health.
New HIV outbreaks appearing in people who inject drugs, conference told
A switch to a cheaper injectable illicit drug led to a major outbreak of HIV in Tel Aviv, Israel, and should serve as a warning signal for other cities with apparently stable HIV epidemics among people who inject drugs, Israeli researchers warned the 14th European AIDS Conference last month.
Owing to government-funded needle and syringe exchange programmes and opioid substitution therapy, HIV prevalence in Israel among people who inject drugs has been stable for ten years. But, in June 2012, Tel Aviv Medical Center Laboratory noticed that five primary HIV infections had been diagnosed in people who were injecting drugs in a two-month period. Over the following year, a further 40 cases were identified. Every person diagnosed with HIV was also found to have hepatitis C, and they were all people who had been injecting heroin long-term and who had been using the needle and syringe exchange on a regular basis.
It was found that, in early 2012, a large number of people who were injecting heroin began switching to a cheaper injectable substance. Known as 'hagitat' in Israel, the cathinone derivative, also known as 'bath salts', was injected in combination with the opioid substitute buprenorphine (drugs of the cathinone derivative group include the popular club drug mephedrone). Everyone who acquired HIV during the 2012-13 outbreak had switched to injecting 'hagitat'.
Cathinone derivatives were adopted rapidly by drug users in Tel Aviv because they are cheap in comparison to heroin. However, the drug effect is short, requiring up to 30 injections each day and, whereas heroin needs to be dissolved in hot water in a cup or spoon before injection, cathinones must be dissolved in cold water. Cathinone injecting also tends to be a more social activity, and a very high rate of syringe re-use and needle sharing occurs as a result of the high injecting frequency.
Needle and syringe exchange staff launched an education programme among drug users, and also increased the supply of needles, syringes and sterile cups. A rapid, multidisciplinary response is required when shifts in drug use trigger a new outbreak of HIV among people who inject drugs, researcher Dr Eugene Katchman told the conference.
Michel Kazatchkine, the UN Special Envoy on HIV in eastern Europe and central Asia, told the conference that recent outbreaks in Romania and Greece were also driven by the availability of new substances.
Comment: A reminder that harm-reduction services for people who inject drugs are as vulnerable to sudden changes in people’s patterns of drug use as is addiction treatment in general (a classic example being the inability of services for opiate users to cope with the sudden arrival of people injecting crack in the 1980s). Cathinones are a problem that have ‘crept up’ behind much wider concern about methamphetamine, and may be the primary drivers of an increase in injecting and needle sharing in both gay and heterosexual populations. If combined with reduced funding for services for people who inject drugs, and/or hardening public attitudes towards them, the stage is set for a resurgent HIV epidemic in this population, as we are already seeing in Greece.
Pre-test counselling does not reduce sexual risk taking
A randomised controlled trial of rapid HIV testing, with or without risk-reduction counselling, has shown that the counselling is unnecessary and that only a brief discussion before HIV testing is needed. Testing can be provided to more people without counselling, the study shows.
In the control group, participants received a two- to four-minute information session on HIV testing. In the intervention group, participants received a 30-minute counselling session, based on the previously validated RESPECT-2 model. The counselling included a discussion of the person’s risk behaviours and negotiation of a realistic risk-reduction plan that they could commit to. There was also a brief explanation of the HIV test and how its results should be interpreted.
Participants returned six months later and were tested for syphilis, herpes, HIV, gonorrhoea, chlamydia and (in women) trichomoniasis. They also answered questions about their sexual behaviour.
At the start of the study, 1% of the group turned out to have undiagnosed HIV. Six months later, 12.3% of those who had received counselling and 11.1% of those in the control group had acquired a new infection. The difference between these figures was not statistically significant and there were also no significant differences when looking at any specific sexually transmitted infection, or when sub-groups were analysed in terms of age, ethnicity, gender or substance use. However, men who have sex with men who received the counselling intervention had significantly more HIV infections (18.7%) than men who have sex with men in the control group (12.5%).
Furthermore, there were no differences between the intervention and control groups in terms of the number of partners and amount of unprotected sex that they reported.
A financial analysis showed that it cost US$23 to test each person in the control group, rising to US$56 in those receiving counselling. Providing the counselling is not an efficient use of resources, according to the investigators.
Comment: It is very important to emphasise what this study does not show. It does not show that risk-reduction counselling as a technique is ineffective in reducing sexual risk behaviour; in fact, a number of studies have shown that it is effective in both individuals and couples. The counselling intervention was not intended to be an in-depth discussion of the pros and cons of testing and was not part of a formal informed-consent procedure. And the study says nothing about post-test counselling in those diagnosed with HIV, which is generally seen as essential and has also been shown to be effective in people seeking post-exposure prophylaxis (PEP). What it does show is that including a mandatory sexual-risk counselling session before people take an HIV test is not necessary, has no effect on subsequent risk behaviour and, in gay men, may even be counter-productive.
Researchers and advocates discuss the microbicides pipeline in Europe
The 14th European AIDS Conference featured a satellite symposium on development of HIV microbicides, sponsored by the CHAARM (Combined Highly Active Antiretroviral Microbicides) Project, a consortium of 29 research projects from nine European countries, South Africa and the US, and the community partner, the European AIDS Treatment Group.
A microbicide, in the broadest sense of the word, includes any compound taken or administered before or during sex, or other HIV exposure, to reduce the risk of infection. Globally, microbicides currently under study include gels – used both before or after sex and every day, vaginal rings and long-acting injectables, as well as daily or pre-sex oral PrEP (pre-exposure prophylaxis).
A rectal microbicide trial, MTN-017, was launched last month; the FACTS 001 trial, currently underway in South Africa, is trying to replicate the success of the one topical microbicide gel so far found to be effective, in the CAPRISA 004 study; and the ASPIRE and RING studies are studying the effectiveness of a vaginal ring containing the drug dapivirine (TMC 120), an NNRTI (non-nucleoside reverse transcriptase inhibitor) drug not used in HIV treatment.
For CHAARM, York University, one of the CHAARM partners, will be running DAPIDAR, a randomised controlled study to assess the safety of two weeks' use of two next-generation vaginal microbicide formulations containing either the protease inhibitor darunavir, or dapivirine plus darunavir. This will start in early 2014.
Other than DAPIDAR, CHAARM’s studies are mainly of experimental compounds that could be used in next-generation microbicides. These include new NNRTI drugs, a new class of drug called LEDGINs, small protein molecules, and a unique kind of antibodies originally found in llamas. These new compounds probably will not be used as single agents but offer potential for combination approaches.
Janneke van de Wijgert of the University of Liverpool warned of the safety challenges of vaginal and rectal microbicides. It is important that products not discourage 'friendly' bacteria or encourage growth of harmful pathogens, she said.
Harriet Langanke of the German Sexuality and Health Foundation discussed how microbicides could be marketed if reliably effective ones were developed.
Products for HIV prevention should be adaptable to individual preferences and use in a variety of settings, ranging from casual encounters to sex work to long-term relationships. "When talking about microbicides we should be talking about sex and sexuality and whether these products improve pleasure," she emphasised.
Finally, EU commissioner Alessandra Martini discussed the role of the European Commission in microbicide research. The European and Developing Countries Clinical Trials Partnership (EDCTP) is supporting a variety of microbicide projects, both at the capacity-building and the clinical trial stages, she said.
Other recent news headlines
HCV reinfection is common among HIV-positive gay men in Europe
Eighteen per cent of HIV-positive men acquired hepatitis C virus (HCV) a second time after clearing the virus, with some having third and fourth infections as well, according to findings from the European AIDS Treatment Network (NEAT) presented at the 14th European AIDS Conference last month in Brussels.
Harm reduction works: extremely low HIV incidence over almost 20 years among people who inject drugs in Australia
Incidence of new HIV infections among people who inject drugs in Australia is extremely low. Investigators examined incidence among people who inject drugs who had repeat HIV tests between 1995 and 2012. The annual incidence rate remained low throughout the study period at just 0.11% (one case a year in every 909 people). The investigators attribute this “remarkable” prevention success to the early introduction of free and legal syringe and needle exchange programmes in Australia.
HIV may be becoming less fit as it adapts to the immune system
HIV, at least in some parts of the world, may be developing a lower replicative capacity as it adapts to variations in the human immune system, studies in southern Africa and elsewhere suggest. The AIDS Vaccine conference heard last month that competition between HIV and certain varieties of human HLA (human leukocyte antigen) genes may be contributing to a diminution in HIV virulence, a lower community viral load, and an increased proportion of ‘elite controllers’ in the population.
Audit shows many high HIV prevalence areas in England are failing to expand HIV testing
Most sexual health commissioners for areas in England with a high HIV prevalence have introduced some form of expanded HIV testing, a study published in the online edition of HIV Medicine shows. However, only a small minority were following national guidance, with just a third having commissioned testing for new registrants in general practice and 14% commissioning testing for people admitted to hospital.
Editors' picks from other sources
France okays home tests for HIV
from Global Post
Self-testing HIV kits will go on sale in France next year under a strategy aimed at reducing the spread of the virus, Health Minister Marisol Touraine said. In-home tests will be available "for people who do not want to go to testing centres or hospitals" to learn about their HIV status, she told a parliamentary committee.
HIV infection rate in Russia has grown 7% this year
from RIA Novosti
The HIV infection rate in Russia has grown 7% this year, according to state statistics. Annual incidence in the general population is more than 0.1% a year in several regions in the Ural Mountains and Siberia. Sharing equipment for drug injection remained the primary cause of infection, accounting for 58% of all new cases. About 54,600 new infection cases were diagnosed in the country in the first nine months of this year. In November 2012, the total number of people living with HIV in Russia was estimated as 730,000 – three to four times the prevalence typical in western Europe.
Survey shows ignorance among Scots about HIV facts
from BBC
More than half of Scots do not know all the ways HIV is transmitted, according to a new survey. One in 10, for instance, wrongly believe it can be passed on by kissing. The findings were released as part of a campaign, backed by singer Annie Lennox, to tackle the stigma around HIV in Scotland, where it affects almost 6000 people.
Hormonal contraception + HIV + limited data = “a public health conundrum”
from Science Speaks
Does the use of injectable hormonal contraceptives increase the risk of a woman acquiring HIV? And if a woman has HIV, does her use of an injectable hormonal contraceptive increase the risk that her uninfected male sexual partner will get HIV? Chelsea Polis, senior epidemiological advisor at USAID, who has considered more questions surrounding hormonal contraception and HIV than most people know even exist, say: “We may have no answer for some time, and some might argue we may never have a clear answer.”
Trial of game-changing new anal condom begins in Boston
from Gay Star News
A revolutionary anal condom that simulates condom-free sex is being trailed in Boston by the US National Institutes of Health in the hopes of encouraging more people to engage in safer sex. The anal condom is being tested by Boston’s Fenway Institute.
The importance and difficulties of conversations between lovers about STIs
from Medical News Today
Having sex can be fun; and talking about sex can be fun. Talking about sexually transmitted infections with a potential sexual partner, however, is a totally different matter, according to new US research. The study found a disconnect between the public health messages that promote STI testing as a way to prevent STIs such as HIV and chlamydia and the conversations – or lack of them – occurring in bedrooms.