Eastern European governments fail to take action
Eastern Europe is facing a quadruple epidemic of injecting drug use, HIV, tuberculosis and hepatitis C, but governments are failing to take action, the United Nations’ Secretary-General’s Special Envoy on HIV in central and eastern Europe, Professor Michel Kazatchkine, recently told the 14th European AIDS Conference in Brussels.
“If the epidemic in eastern Europe is not brought under control, it will be the governments of the region who will bear responsibility for the human tragedy that is unfolding in their countries,” he said.
In the region, the prevalence of HIV has increased by 140% in ten years, AIDS deaths are rising and only 30% of people who need HIV treatment can access it.
Although injecting drug use is a key transmission route, there is political resistance to tackling the issue and the limited harm-reduction programmes that do exist are largely funded by external donors. Kazatchkine said that even relatively small increases in the provision of needle exchange, opioid substitution therapy and HIV treatment could reduce HIV infections significantly, as long as the three approaches were used together.
About 40% of HIV infections in the region are described as ‘exposure group unknown’. Many are likely to be the result of sex between men, which is under-reported because it is stigmatised and often illegal.
In Russia, legislation has recently outlawed the “spreading of information about non-traditional sexual relationships”. The law is likely to inhibit HIV prevention activities targeting men who have sex with men. A similar law has recently been passed in Moldova and was narrowly rejected by Armenia’s parliament last month.
The European AIDS Clinical Society (EACS) strongly condemned the discriminatory legal and policy environment being created. “We are concerned that these provisions not only affect basic human rights, but also result in harmful public health policy since they add to the already-existing barriers related to HIV prevention, diagnosis, access and retention in care”, EACS stated. “The legal framework in States should do everything to reduce stigmatisation.”
Professor Kazatchkine called on the European Union to focus on health issues in the region, with a clear ethical stance against homophobia and xenophobia. Moreover, it should have a particular focus on EU members in the Baltic region and in south-eastern Europe, he said.
Comment: Russian politicians have been extremely resistant to lobbying from foreign politicians on questions of human rights. While lobbying by foreign non-governmental organisations or clinicians may not have an immediate impact, it may encourage local physicians to speak up. In Ukraine, patients have recently successfully fought for better access to treatment and diagnostics.
EACS guidelines – treatment as prevention
Nonetheless the guidelines state that, in all cases, HIV treatment should be “considered” and “actively discussed” with the patient. The document mentions the ability of treatment to reduce transmission of HIV as a potential reason to take it.
The authors say that their recommendations had to balance “individualised treatment with public health”.
Comment: The writing committee was mindful of the limited access to antiretroviral treatment in many European countries. The guidelines state that priority should be given to patients with a CD4 cell count below 350 or with a co-morbidity, rather than individuals wishing to take treatment for prevention purposes. In contrast, guideline writers in the relatively well-resourced settings of France and the United States have recently recommended therapy for all people with diagnosed HIV.
Making treatment as prevention a reality for people who inject drugs
People who inject drugs risk being left behind as countries make efforts to scale up antiretroviral treatment, unless greater efforts are made to develop appropriate services, according to speakers at Controlling the HIV Epidemic with Antiretrovirals: From Consensus to Implementation, a recent conference in London.
Achieving very high rates of viral suppression among people who inject drugs presents a distinct set of challenges regarding engagement in care and adherence to treatment. In the United States, for example, people who inject drugs are more likely to be incarcerated, less likely to have health insurance, less likely to have stable housing, less likely to see the same physician at every encounter with the health system and more likely to have substance abuse problems that affect treatment adherence.
Research has also shown a very strong tendency among physicians to defer antiretroviral therapy among people who inject drugs, even when people are in need of immediate treatment.
But with access to treatment so low at present, there is great potential for this to be improved and for a prevention benefit to be realised. The Canadian province of British Columbia is frequently highlighted as demonstrating the impact of a ‘seek and treat’ policy on new HIV diagnoses.
The province has seen a 1% decline in HIV diagnoses for every 1% increase in treatment coverage, with the improvements being most pronounced in people who inject drugs.
But other Canadian provinces have not followed the same policy, influenced by federal politicians who have taken a moralistic attitude to the issue.
Comment: In British Columbia, harm-reduction services, including a supervised injecting facility, have expanded significantly in the same period of time as the ramping up of treatment access. There are likely to have been synergies between the two programmes, which may explain why new HIV infections have fallen further in injecting drug users than in other groups. Moreover, the province’s approach to improving the uptake of treatment involves addressing barriers such as addiction, mental health and homelessness. Holistic services which deal with a range of health and social issues are likely to have greatest success in retaining individuals who inject drugs.
Who will take PrEP?
Screening tools to identify people who would benefit from PrEP may need to be developed, as people are not always very good at estimating their own risk. For example, one study showed that one-in-seven gay men considered themselves at increased risk of HIV infection, while an ‘objective’ assessment used by researchers found that three-quarters of the men were at increased risk.
But perceptions of PrEP may change over time and with experience. Doctors in San Francisco report that people taking PrEP perceive advantages including decreased anxiety about transmission, increased communication and disclosure to partners, more intimacy and trust, greater sexual pleasure, and an increased sense of self-efficacy. Disadvantages included feeling stigmatised because of PrEP’s associations with HIV or with risky sex, and negative attitudes from some healthcare workers.
Comment: Taking PrEP each day requires people to anticipate that they will need extra protection from HIV, but with condoms frequently presented as being 100% effective and with non-condom use highly stigmatised in certain contexts, acknowledging that risk may be challenging for some individuals.
Late HIV diagnosis is a Europe-wide problem
Late diagnosis of HIV remains a serious problem across Europe, results of a large study show. Previous research has analysed late diagnosis rates in individual countries, but little is known about trends across Europe and data from eastern Europe are scarce.
The study included data on over 85,000 people diagnosed with HIV between 2000 and 2011 in 35 European countries. Overall, 54% of patients were diagnosed late (with a CD4 cell count below 350 cells/mm3) and 33% presented very late (with a CD4 cell count below 200 cells/mm3).
Rates of late presentation were especially high among heterosexual men, migrants from Africa and other regions, older people and those living in southern Europe.
There was a marked fall in the proportion of gay men and heterosexual people in central and northern Europe diagnosed late over the course of the study. The rate of late presentation also decreased over time among heterosexual women in eastern Europe.
However, the rates of late diagnoses increased in male injecting drug users in southern Europe and among male and female injecting drug users in eastern Europe.
Late diagnosis was associated with increased rates of AIDS and death, particularly in the first year after HIV diagnosis.
Comment: As well as putting individuals at risk of serious illness, late diagnosis is an indicator of problems with HIV testing policy and practice. Individuals whose infection remains undiagnosed cannot benefit from antiretroviral treatment, may have an elevated viral load and may be unwittingly putting their partners at risk of infection.
Vaccine research
The 13th AIDS Vaccine conference took place in Barcelona this month. Despite opening just as another vaccine efficacy trial with negative results published its findings, the scientists there were more optimistic than for some time about the prospects for eventually finding an effective vaccine. In particular, there was excitement about a vaccine studied in monkeys which uses a common herpes-type virus called cytomegalovirus (CMV) as the vehicle for delivering inactive proteins from the monkey equivalent of HIV. This vaccine did not prevent infection, but almost half of vaccinated monkeys controlled the infection or cleared it altogether.
A vaccine which showed a modest protective effect in a human study in Thailand will be tested in further trials in South Africa and Thailand to see if the level of protection can be improved. If this vaccine proves effective in these trials, it might be licensed for use in some populations by 2022. To be put forward for marketing approval, trials would have to show that the vaccine was safe and that it reduced the risk of infection by at least 50%.
A team from Oxford University announced early results from a trial of a potentially powerful vaccine made from stringing together the most immune-stimulating elements of HIV. And, in the longer term, vaccines based on the herpes family of viruses may prove to be as effective and versatile in humans as they are in monkeys, with an early announcement of a TB vaccine using the same concept, and another combining an HIV vaccine with the existing chicken-pox vaccine.
Female condom choices are expanding
The first model of female condom, the Femidom, was introduced in 1993, replaced in 2007 by an improved version that is softer and less noisy. Other manufacturers have now developed several alternative versions that have varying features, shapes, materials and degrees of lubrication.
A study comparing four different models found that each had a low rate of failures such as the device breaking or slipping out of the vagina, or the penis being inserted between the condom and the vaginal wall. The models were also highly rated by the women using them, in terms of their feel and ease of use.
All four models have received the European Union’s CE mark (i.e. they meet EU safety, health and environmental requirements).
Comment: One of the key barriers to more widespread use of female condoms has been the frequent lack of programmes which promote and distribute them. Interventions which encourage heterosexual people to find a condom which suits them (in terms of size, shape and material) need to raise awareness of female condom options.
Other recent news headlines
Specialised testing and social marketing campaigns increase the detection of acute HIV infection among gay men
Canadian clinicians have demonstrated that a large increase in the diagnosis of acute (very recent) HIV infection can be achieved, by using pooled NAAT tests alongside traditional antibody tests and by promoting HIV testing in social marketing campaigns for men who have sex with men. The policy change resulted in a significant increase in the number of men diagnosed with acute HIV infection, from 1.03 per 1000 men testing before the policy change, to 1.84 per 1000 men afterwards. The new testing policy was only implemented in clinics which diagnose large numbers of gay men, and was particularly effective in one community-based clinic – this site diagnosed one third of the acute infections alone.
Many HIV-positive people not receiving recommended prevention counselling
Half of HIV-positive people in the United States are not receiving sexual health counselling as part of their routine care, a study has shown. Only 44% reported receiving individual advice from healthcare providers; while just 30% received it from HIV-prevention workers and 16% had participated in a small group intervention in the past year. Individuals who did receive counselling were more likely to have a low income, not to be of white ethnicity and to report risky sex. Nonetheless, only 61% of those reporting unprotected sex received an intervention.
Men attending ‘slam parties’ don’t all inject drugs
A survey has highlighted divergences in the practices of French men attending ‘slam parties’. These events are normally understood to be group sex parties where gay men take drugs such as methamphetamine or mephedrone, often by injection, in order to facilitate prolonged sexual activity. Almost all attendees used some drugs, but a significant minority did not inject drugs, and some did not have unprotected sex.
Editors' picks from other sources
Michel Kazatchkine: 24 hours in Bucharest
from Huffington Post
Last week, I went on a short visit to Bucharest to understand the origin of the recent outbreak of HIV among people who use drugs in the city. I am disheartened to say that the fears of many of us working in global health held about the potential negative impact on the HIV/AIDS epidemic caused by the withdrawal of the Global Fund to Fight AIDS, Tuberculosis and Malaria from a number of countries, including Romania, have been realised.
Local and regional authorities provide innovative solutions to ensure health care for undocumented migrants
from Platform for International Cooperation on Undocumented Migrants (PICUM)
While national level policies and funding frameworks often restrict undocumented migrants from accessing basic rights such as health care or education, local and regional levels are increasingly finding solutions on the ground. The Platform for International Cooperation on Undocumented Migrants (PICUM) is highly concerned about how these discrepancies impact the role of city authorities and local governments in implementing effective measures ensuring access to basic services for all.
Engagement in care: a final frontier of HIV medicine
from Treatment Action Group
Far too many people living with HIV aren’t accessing the care they need to benefit from the personal and public health benefits of antiretroviral therapy. Whereas we have hundreds of clinical trials to determine which HIV treatment regimens to use in particular circumstances, the evidence base to inform engagement-in-care practices and policies is limited at best.
Researchers launch first-ever phase II safety study of rectal microbicide to prevent HIV
from Eurekalert Inf Dis
Taking an important step toward the development of a product to prevent HIV infections associated with unprotected anal sex, researchers today announced the launch of a global phase II clinical trial of a potential rectal microbicide. The trial, led by the US National Institutes of Health-funded Microbicide Trials Network, is testing the rectal use of a reduced glycerin gel formulation of the antiretroviral drug tenofovir.
Switzerland: yes to the Epidemics Act: discrimination in penal cases against people with HIV eliminated
from Positive Council
Swiss voters have said yes to the new Epidemics Act. This puts an end to the many years of discrimination in penal cases against people with HIV. Under the new Epidemics Act, the transmission of a dangerous human disease is only prosecutable if the perpetrator acted with malicious intent.