April 2013
Self-testing is feasible, acceptable and accurate, studies find
Twenty-one separate studies have found that self-testing kits for HIV are easy to use, acceptable to at least three-quarters of people offered them, generally highly accurate, and do not result in adverse outcomes like suicide. However, researchers only identified one randomised controlled study of self-testing and only one study that assessed linkage to care after a positive test.
Two-thirds of the studies evaluated self-testing using oral swab samples; the others looked at self-testing using fingerprick blood samples. Two-thirds were concerned with supervised self-testing, with a healthcare professional present during the test though not performing it, so only seven studies looked at people testing alone.
Acceptability of supervised testing ranged from 74% among US gay men to 100% among Canadian students. The acceptability of unsupervised testing was only documented in two studies, and was 78% among healthcare professionals in Kenya and 84% in non-monogamous US urban gay men.
False-negative results were almost unheard of. False-positive results were occasionally recorded, with a rate as high as 7% in one US study. No more than 5% of people in any study made mistakes in the testing process or were unable to interpret the result.
Only one study on unsupervised testing reported on linkage to care after a positive result, and in this, 96% of people testing HIV positive said they would seek post-test counselling. Evidence of extreme adverse outcomes, such as suicide following an HIV-positive result, was “entirely absent”.
Low-income populations in all settings tended to prefer free self-testing kits, whereas a cost of up to US$20 was generally acceptable for more affluent individuals.
Comment: This meta-analysis is largely reassuring and shows that home testing should be feasible and not result in a high proportion of test failures or false-positive or -negative results, though an isolated instance of 7% false-positive results is of concern. More studies of totally unsupervised testing in different settings and populations, however, are needed to get a really accurate idea of how people may use self-testing in practice.
‘Test and treat’ not enough to end gay epidemic, US model finds
HIV prevalence in US gay men would not fall even if every man took a test annually and everyone diagnosed took antiretroviral therapy (ART), a mathematical model suggests. The model finds that these measures would lead to the annual number of new HIV infections in gay men almost declining to the annual number of deaths, but not quite. However, they would produce a 34% reduction in the cumulative number of new infections, and a 19% reduction in cumulative deaths by the year 2023, the model finds.
The model also finds that universal treatment would lead to a doubling in the prevalence of multidrug-resistant HIV, although this would not lead to an increase in deaths or progression to AIDS. This prediction may be based on out-of-date data, however.
The model’s assumptions are all derived from observed trends in HIV infection in Los Angeles gay men between 2000 and 2010. Currently, in Los Angeles, gay men have HIV tests, on average, every 4.4 years. The researchers used the model to find out what would happen if this frequency was increased to every three years, every two years, and every year.
Similarly, the average time between HIV infection and starting ART in gay men in Los Angeles has been calculated as 2.5 years. The researchers modelled what would happen if this was reduced to one year or to six months.
If nothing changed, the researchers’ model predicts, there would be 54,000 new infections, 49,000 AIDS diagnoses and 42,000 deaths between 2013 and 2023.
If average testing frequency increased to one test a year in addition to all starting ART on diagnosis, then the cumulative number of new infections by 2023 would fall to 35,800, of new AIDS cases to 30,000 and of deaths to 34,100. The number of people unaware of their infection would fall considerably, to only 4%.
The model also predicts that the proportion of people with multidrug-resistant HIV would increase to 9.1%. However, this particular output from the model derives from data on the prevalence of primary HIV drug resistance that are more than seven years old and does not take into account falls in multidrug-resistant HIV since then, or the arrival of new classes of HIV drugs.
Comment: This model’s strength is that, because the researchers based its parameters closely on data from a specific place and population, it may give a more realistic idea of the influence of expanded testing and treatment than more idealised studies. This is its weakness too, though: because it is based closely on historical data, it cannot take account of trends that have recently changed, such as the increase in treatment success and the resultant decline in multidrug-resistant HIV following the introduction of more tolerable drugs and new classes of drugs.
More women than men on treatment have detectable genital HIV
Persistently replicating HIV has been observed in the genital tract of a considerably larger minority of women taking antiretroviral therapy (ART) than of men. And in untreated women, genital viral loads were especially high in women with HIV subtype C, the predominant type in the world’s highest-prevalence countries in south and east Africa.
A study looked at men and women in seven different countries who started ART. Viral load in blood plasma and genital fluids was monitored at baseline and again after one and two years of treatment.
Before starting ART, HIV was detected in 82% of semen samples from men and in 86% of cervical samples from women. Women with subtype C had twelve times the cervical viral load of women with subtype B, twelve times the seminal viral load of men with subtype C, and 20 times the viral load of men with subtype B.
ART suppressed genital viral load in the majority of women and men. However, two years after starting ART, 97% of men but only 84% of women, regardless of subtype, had no detectable HIV in their genital fluids, and this 13% difference was statistically significant.
It is not known whether low-level genital tract replication of HIV in people on ART contributes to HIV infection. In the HPTN 052 study, in multivariate analysis, women not on ART were 37% more likely to transmit HIV to men than vice versa, but this difference was not statistically significant. The one transmission from someone on ART was from a man to a woman and if there were any subtle gender-based variations in infectiousness, they were outweighed by the 96% efficacy of ART in stopping infections. Nonetheless, the reasons for the higher genital viral load in both women and in people with subtype C deserve further investigation.
Comment: There is still a lot we don’t know about HIV replication in the genital tract, and more research is needed. This is relevant not only to studies to find out whether those on successful ART can still infect others, but also to studies of exactly how oral pre-exposure prophylaxis (PrEP) and microbicides get into tissues and stop mucosal HIV infection. We know even less about HIV in the rectum, and similar studies of rectal HIV viral load need to be done.
Little change in English gay men’s sexual risk behaviour from 2001 to 2008
The study also found that the proportion of men who had ever had an HIV test increased by 50% over this period and that the proportion who said they knew they had HIV almost tripled.
From 1997 to 2008, Sigma Research conducted the annual Gay Men’s Sex Surveys, at first recruiting men at gay venues and festivals but later switching largely to the internet. However, there have always been difficulties in using these surveys as a longitudinal dataset, partly because, as a self-selected group, respondents differed between years, and partly because the same set of questions was not used each year. In 2001 and 2008, however, Sigma asked the same set of detailed questions about sexual behaviour.
In 2008, the sample was considerably older, with higher levels of education and somewhat more ethnically diverse. After statistical adjustment, men in 2008 were around half as likely to report that they had never tested for HIV.
Among men who had either tested negative or never tested, there were statistically significant falls between 2001 and 2008 in the number of men who had had five or more sexual partners in the past year. In terms of UAI, this was reported by 59% of men in 2001; 57.5% of men in 2008 said they had had UAI at least once in the last year. Among men with HIV, however, the proportion reporting UAI increased from 73% in 2001 to 82% in 2008, meaning they were over twice as likely to report UAI as HIV-negative men.
The authors say that their data are suggestive of “a growing concentration of risk among men with diagnosed HIV”, who appear to be more likely to report having unprotected anal intercourse and multiple partners.
Comment: What’s surprising about studies of gay men’s HIV risk behaviour since the introduction of ART is how unchanging their findings are: this is one of a number of studies that have found that a little over half of gay men report that they sometimes have unprotected anal sex, and that this has scarcely changed since 2000. The signs of ‘sero-segregation’ of HIV-negative and -positive gay men are perhaps an inevitable result of men trying to reduce their HIV risk, but have disturbing implications for the sexual health and social isolation of men with HIV. HIV testing rates have continued to rise since 2008, but the challenge now – addressed in a new HIV prevention campaign in England – will be to increase testing frequency.
Most gay couples have ‘extramarital sex’ agreements – but don’t always agree what they are
Researchers have found that most US gay men in relationships establish a ‘sexual agreement’ with their partner, both to minimise HIV risks and to maintain the quality of their relationship. However, partners do not always agree on whether they have an agreement, on whether it was explicitly discussed, or on what sex is allowed with other people. And the agreement had been broken by one or both partners in just under half the couples studied.
In the study of 361 couples, 70% reported having a sexual agreement, but in 25%, one man thought there was an agreement, while his partner said that there wasn’t. For 56% of men who thought they had an agreement, it was that the relationship was monogamous. For a further 41%, the agreement was to permit sex with casual partners, but with some rules or guidelines. In 46% of cases, either one or both partners had broken the rules at some point during the relationship.
The main reasons for breaking agreements were sexual frustration and the ‘heat of the moment’. Only a minority of men (30%) told their partner that they had broken the agreement. Reasons given for not disclosing included not giving the partner a reason not to trust the respondent and fearing that this could lead to the relationship ending.
The study also found that around a quarter of the HIV-negative men who have casual sex attempt to 'serosort' or use 'strategic positioning' when doing so. However, regular HIV testing was far from universal in this group, making such practices potentially unreliable.
Comment: This study’s findings are very similar to a previous study from San Francisco in 2005 (more detail on aidsmap.com in ‘Negotiated safety’; see reference 3 on that page). In that study, however, fewer partners agreed to monogamy. The biggest barrier to the safety of these agreements, in terms of preventing HIV, is not that they get broken but that men fail to test for HIV after they have unprotected sex outside their relationship. As a result, the ‘HIV negative’ status of many may be more a matter of hope than certainty.
European HIV prevention webinars – pre-exposure prophylaxis (PrEP)
As part of its European HIV prevention work, NAM is collaborating with AVAC to provide a series of webinars (conference calls with accompanying slides) to train and inform prevention advocates and anyone interested in the newest developments in HIV prevention technology.
The fourth webinar is entitled:
PrEP – news from studies in Europe and elsewhere
This 90-minute webinar will look at the current situation regarding pre-exposure prophylaxis (PrEP) in Europe and the US. It will look at the ongoing IPERGAY study in France and the PROUD study in England, as well as reviewing progress in the NEXT-PrEP and demonstration studies in the US. It will also discuss the implications of the negative results of the recent VOICE trial. The presentations will be followed by a question and answer session with our expert speakers. The webinar will be conducted in English.
Time and date: 2pm UK time (BST), Thursday 9 May (3pm CEST)
To register for the webinar and get phone numbers and joining instructions click this link:
https://cc.readytalk.com/r/9rp8k6ka35y2
European advocates interested in learning more about PrEP, the opportunities and challenges it may present for existing ways of doing HIV prevention work, and possible barriers to its implementation, are encouraged to join this webinar and to email questions in advance to info@nam.org.uk. During the event, participants will be encouraged to ask questions by telephone.
Other recent news headlines
Hepatitis C epidemic in US gay men is decades old
Hepatitis C virus (HCV) transmissions have been occurring in gay men since at least the early years of the HIV epidemic, investigators from the US report. The vast majority of infections involved men living with HIV. The investigators found evidence of HCV transmissions from the very beginning of the HIV epidemic. There were 41 new infections among HIV-positive men between 1984 and 1989, and eight in HIV-negative men during the same period.
Lukewarm reaction to government’s sexual health framework for England
Just two weeks before local authorities took over the commissioning of sexual health services – and twelve years since a sexual health strategy was last published – the English Department of Health has released a “framework” which outlines the government’s ambitions for the improvement of sexual health in England. But as government policy is for decisions to be made at a local level, the framework does not describe any new programmes, policies or targets. Instead, it provides a brief overview of some of the issues which sexual health services need to address, without giving many clear recommendations for action. “The framework pays far too little attention to HIV at a time when infection rates are high, late diagnosis is common, and almost a quarter of people with HIV in the UK are unaware of their infection,” said Professor Jane Anderson, chair of the British HIV Association (BHIVA).
Very high incidence of high-grade pre-cancerous anal lesions among young HIV-positive Thai gay men
Approximately a third of HIV-positive gay men in Thailand developed high-grade pre-cancerous anal lesions during just one year of follow-up, investigators report. Infection with high-risk strains of human papillomavirus (HPV) was an important risk factor for the development of high-grade lesions. The investigators were extremely concerned by their findings and recommend that healthcare providers, policy makers and communities of gay men will need to make plans for screening and treating pre-cancerous anal lesions.
Editors' picks from other sources
Ukraine's HIV battle
from BBC Radio 4 (audio)
Twelve years ago Lucy Ash investigated Ukraine's fight against HIV infection, which was mainly being transmitted through injecting drug use. After the Orange Revolution in late 2004, the government promised to do everything it could to fight the disease and the situation seemed to improve. But now, Ukraine has the second highest infection rate in Europe, surpassed only by Russia. Around the world, other countries are managing to reduce rates of HIV infection and AIDS-related deaths. Lucy Ash travels to Kyiv and Odessa to see why fighting HIV is so difficult in Ukraine.
Not disclosing HIV should be a crime, say most Canadian gay/bi men
from Globe and Mail
Two-thirds of men who have sex with men believe that people with HIV should face criminal charges if they fail to disclose their status to a sexual partner. Eighty-three per cent said non-disclosure before anal sex should be a crime and 42% before oral sex. Only 17% said failing to disclose should never be criminalized. At the same time, researcher Dan Allman commented, “there is a feeling that legal measures won’t have an impact. There’s an innate understanding that disclosing your HIV status is hard and criminal laws aren’t going to make it easier.”
Doctors warn of rising xenophobia in Europe's healthcare systems
from EurActiv
Austerity measures adopted in Europe in response to the public debt crisis have a devastating impact on healthcare services, resulting in rising xenophobia in countries like Greece and Spain, the humanitarian group Médecins du Monde said recently. Some 81% of patients who showed up at a Médecins du Monde clinic in 2012 had no possibility of accessing care without paying the full cost and 49% had unstable or temporary housing. Among the patients who spoke out about violence, 27% reported having suffered violent acts after their arrival in the host country and 20% reported having been denied access to care by a healthcare provider in the last 12 months (especially in Spain, 62%).
EATG issues Position Paper on European Clinical Trials Regulation
from EATG
The European AIDS Treatment Group, EATG, has adopted a Position Paper on the EU Clinical Trials Regulations, which are currently under discussion within the Council of the EU and European Parliament. EATG welcomes the proposed Regulation for aiming to harmonise the standards for the approval and conduct of trials across European Union countries, ensure the safety of participants and ensure high-quality data. However, EATG argues that quantity and cost of research should always be considered as secondary to the characteristics of true innovation, measurable clinical benefit, scientific validity and ethicality of research. As such, legislation on clinical trials should prioritise tangible benefits to trials participants and the community.
Origami Condoms radically redesigns almost century-old latex protection
from Huffington Post
Origami Condoms, a company in California, has radically redesigned the condom. Their condom, based on Japanese paper-folding ideas, has an accordion-like design that unfolds rather than unrolls and can, they claim, be put on within three seconds. It is also made of silicone rubber that is both softer and more sensitive than traditional latex. Prospective users will have to wait, however: its condoms are currently being tested and will not be on the market till 2015.