High infection rates in men who have previously used PEP
A study from Amsterdam found that gay men who had used post-exposure prophylaxis (PEP) in the past were four times more likely than non-users to subsequently become infected with HIV.
PEP failure does not appear to be the cause of their HIV infection, but rather ongoing risk behaviour following a course of PEP. Self-reported adherence to the PEP regimen was high, at 94%.
The investigators compared HIV infection rates between 2000 and 2009 in 355 men, who had in total received 385 courses of PEP, with infection rates over the same period in 782 gay men entering the Amsterdam Cohort Study. They measured HIV incidence three and six months after receiving PEP in the former group and after cohort entry in the latter.
HIV incidence, translated into infections per man per year, was 6.4% in men who had taken PEP and 1.6% in the cohort study. Three out of the eleven PEP users who acquired HIV were positive three months after PEP but the other eight were only found to be positive six months later, indicating that few - if any - infections were acquired while actually taking PEP.
“Our study showed a high incidence of HIV among MSM [men who have sex with men] who used PEP, an indication of ongoing risk behaviour,” write the investigators. “This implies that PEP alone for this group is not sufficient to prevent HIV infection, and a combination of other more comprehensive preventative strategies is needed.”
Comment: It is important not to interpret this study as a failure of PEP. Instead, it indicates that gay men who come forward for PEP rightly see themselves as being at high risk of HIV, but find that PEP is not a strategy they can use often enough for it to be protective. Previous studies of PEP have also found that, while it has an efficacy of about 80% for individual infections, its use makes no difference to infection rates on a population level. The high HIV incidence in PEP seekers suggests that they might be ideal candidates to be offered an ongoing course of PrEP (pre-exposure prophylaxis). At present, PrEP is still regarded as an experimental prevention technique and access to it is limited to unlicensed or clinical trial-based use.
How to raise awareness of biomedical interventions for HIV: PEP evaluation
Gay men’s awareness of post-exposure prophylaxis (PEP) for HIV significantly improved following implementation of a communications strategy, according to a recent study from Western Australia.
The study is of interest as research of this type – on the impact of communication campaigns on awareness of prevention interventions – is relatively rare. Prevention advocates are considering how to raise awareness of other prevention measures such as PrEP and control of viral load.
In response to data showing low awareness of non-occupational PEP in the gay community and of prescription of PEP outside the guidelines, a PEP awareness campaign was initiated for gay men in 2005 and is still ongoing. The main elements were:
- a leaflet and poster on PEP for distribution via gay venues, sexual health services and partner organisations
- advertising in the Perth gay newspaper and on the Gaydar contact website
- a 24-hour phoneline, staffed by nurses
- distribution of guidelines and related communications to health professionals.
Gay and bisexual men’s awareness of PEP was measured through the Perth Gay Community Periodic Surveys, conducted in 2002, 2004, 2006, 2008 and 2010. Whereas in the two surveys prior to the communication campaign, fewer than a quarter of men were aware of PEP, this rose to over half by 2008.
However, awareness dropped in 2010 to 40%. The authors note that the communication channels and materials have changed little since the campaign began. They say that the 2010 results “suggest that a fresh approach should be considered, which could include opportunities to engage recent trends in social marketing, such as the use of social media”.
Comment: Although, as found in the study above, PEP availability does not make much difference to HIV incidence on a population level, it is an important emergency resource for individuals who may have been exposed to HIV. With new strategies for awareness-raising of biomedical prevention possibilities being considered, the success of this campaign will be keenly noted by prevention advocates.
French youth study: knowledge about HIV and trust in condoms has decreased
The study found that although condoms are still widely used and that use in young people who have multiple partners has not decreased, there have been decreases in condom use between partners in long-term, committed relationships.
The French Knowledge, Attitudes, Beliefs and Practice (KABP) survey has been conducted on six occasions since 1992. It found that knowledge about the most important routes of HIV transmission, via unprotected sex and unsterilised needles, is almost universal, but that in recent years young people have become more likely to believe in non-existent HIV transmission routes. In the most recent survey, one-in-five people thought you could acquire HIV from using a public toilet and one-in-four men and one-in-six women thought mosquitoes transmit HIV.
Although most young people thought condoms provide some protection against HIV, only just over half of respondents thought that they provided complete protection, compared with over three-quarters believing this in the 1990s.
While nearly half of participants said they were scared of developing AIDS in the 1990s, this has now declined to one-in-five participants, not a significantly larger proportion than the one in six who said they were afraid of other sexually transmitted infections (STIs). Yet at the same time, the proportion who thought they could possibly have already acquired asymptomatic HIV has gone up, to over a third of respondents.
Only a quarter of young women and half of young men said they used a condom the last time they had sex, a 37% decrease in women and a 27% decrease in men from the 1990s. Condom use has remained high in young people with multiple partners and in men having one-night stands but has declined in steady partnerships. One-in-five men said they took no contraceptive or sexual health precautions at all, compared with one in ten in the 1990s.
Comment: This study presents a mixed picture. It is encouraging in that it shows that condom use has remained high among young people at the highest risk of STIs and HIV, but shows that fewer people are using them in committed relationships. As the researchers comment, young people may now be more concerned about pregnancy than HIV and may perceive HIV as little worse than other sexually transmitted infections, so condom use has slipped downwards in the hierarchy of sexual health measures.
Low use of behavioural interventions in English STI clinics
Only a limited number of gay men are offered and accept a structured discussion on risk reduction, an audit carried out at 15 sexual health clinics in England has found.
England’s National Institute for Health and Clinical Excellence (NICE) recommends that people who are at high risk of having a sexually transmitted infection (STI) should be offered such an intervention. These one-to-one discussions should be structured on the basis of behaviour change theories and should last at least 15 to 20 minutes. The British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) make similar recommendations.
A case-note review found that four–in-ten patients received a behavioural intervention, but frequently this was just advice. Fewer than one in ten received a structured intervention, as recommended. Interventions delivered were mostly counselling and motivational interviewing; a handful of men received cognitive behavioural therapy or peer education.
The researchers examined the notes of 598 HIV-negative gay or bisexual men who attended in June 2010. Ninety-two per cent of men accepted an HIV test and 43% had taken at least one more test in the following year.
Although the case notes record that 251 men accepted a discussion on risk, only 52 received a structured intervention based on behaviour-change theories, as recommended by NICE. Only 42 men were recorded as actually refusing a risk discussion, but it is not a requirement that the notes have to record refusals.
The authors recommend that the reasons why such interventions are not offered to men at risk of HIV infection are investigated and addressed. There was great variability in how clinics defined ‘at risk’ and the researchers suggest that STI clinics need a standard risk assessment tool, such as the one developed for the PROUD pre-exposure prophylaxis (PrEP) study. They recommend that clinic staff be provided with more resources and training to conduct structured discussions, and that they are made aware of the relatively recently published guidelines.
Comment: Because refusals were not always recorded, it is difficult to know whether only one-in-ten men in this study received the recommended structured intervention mainly because few were offered, or because there was a high refusal rate of any discussion on risk. Experience with HIV testing in non-traditional settings suggests that resource constraints and staff inexperience are the most common reasons for interventions not being taken up, but how the subject of risk is broached with patients needs investigation too.
European HIV prevention webinars
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 first webinar is entitled:
European Contributions to the Search for an HIV Vaccine
This webinar will examine current European efforts in HIV vaccine research and will provide an opportunity for advocates to ask questions of a range of expert speakers. The webinar will be conducted in English.
Time and date: 2pm UK time (GMT), Tuesday 29 January
This 90-minute webinar will provide advocates with an overview of European efforts to develop an HIV vaccine through national and EU-funded programmes. The presentations will be followed by a question and answer session with our expert speakers.
The webinar will by feature presentations by:
Dr Gabriella Scarlatti – The ANRS and EU funded efforts
Dr Gabriella Scarlatti is on the faculty at the San Raffaele Scientific Institute, Milan, Italy and Head of the Viral Evolution and Transmission Unit there. She recently headed the EU funded NeutNet program, a group aimed at standardising methods for the measurement of neutralising antibodies to HIV for use in human clinical trials of candidate HIV vaccines.
Dr Eric Sandström – Karolinska Institutet funded efforts
Dr Eric Sandström is on the faculty at the South Hospital, Karolinska Institutet. Karolinska Institutet studies the safety of preventive HIV vaccines and the effect of therapeutic vaccines as an addition to antiretroviral therapy. Dr Sangstrom has been the investigator on vaccine trials in Tanzania.
Kevin Fisher – European investment in HIV vaccines to date
Kevin Fisher is director of the HIV Vaccines and Microbicides Resource Tracking Working Group, which includes UNAIDS and IAVI, and has tracked European investment in HIV vaccines since 2000.
The discussion will be introduced and moderated by Rebekah Webb. Rebekah is a freelance consultant specialising in advocacy and resource mobilisation for global health. She provides ongoing support to the work of AVAC in Europe. From 2003 until 2009, Rebekah was the European Coordinator of the Global Campaign for Microbicides, working with civil society organisations and networks in 15 countries.
European advocates interested in learning more about vaccines and the role that Europe is playing in the global search for an HIV vaccine are encouraged to join this webinar and to email questions in advance to avac@avac.org. During the event, participants will be encouraged to ask questions via telephone.
To register for the webinar and get phone numbers and joining instructions: click this link
The following webinar, on Tuesday 26 February, will examine European microbicide research.
Other recent news headlines
Vaccinating men against HPV could prevent anal cancer
A study of pre-cancerous conditions in gay men with HIV, caused by the human papillomavirus (HPV), has found that 71% of cases could be prevented by vaccination with the currently available vaccine Gardasil and 89% with an experimental vaccine that protects against nine cancer-associated variants of HPV. The British Medical Association recently urged the UK government to start providing HPV vaccination to young men as well as young women.
Testing and counselling couples leads to high rates of condom use in South Africa
A substudy of the Partners in Prevention study finds that testing and counselling people as couples, rather than individuals, leads to high rates of consistent condom use. Seventy-one per cent of individuals in the couples who tested HIV positive reported unprotected sex before testing, and a month later this had fallen to 25%. But couple counselling in which HIV status and safer sex were discussed reduced the prevalence of unprotected sex further, to just 8%.
Sex-worker clinics reduce risk behaviour
Another South African study, of male, female and transgender sex workers in South Africa, found that the provision of clinics and mobile outreach facilities targeted specifically at sex workers significantly reduced rates of unprotected sex. Sex work is criminalised in South Africa and little research into or provision for this group has been provided. The study also advocates for more provision of female condoms for women sex workers as although 73% said they ‘liked’ them, only 44% had ever used one.
Editors' picks from other sources
HIV transmission risk almost zero if heterosexual partner has undetectable viral load
from NATAP
A multistudy review of HIV-discordant heterosexual couples estimated an HIV transmission rate of zero to 0.31 per 100 person-years when the positive partner has an undetectable viral load because they’re on antiretroviral therapy. The researchers said this means that if 1000 heterosexual couples whose HIV-positive partner had an undetectable viral load had sex for a year, one would expect between one and two HIV transmissions. This infection rate is 550 times (99.8%) lower than the transmission rate between couples where the HIV-positive partner was untreated seen in the HPTN 052 treatment-as-prevention study.
Why we need a PrEP trial among gay men in the UK
from Medical Research Council
The UK’s Medical Research Council (MRC) has published a policy brief detailing the thinking behind the new open-label study (the PROUD study mentioned above) of pre-exposure prophylaxis (PrEP) in gay men. Enrolling in the pilot phase started in December, as of mid-January one of the 14 clinical sites had almost competed enrolment, and all sites were expected to start by the end of February.
Better syringe designs could nearly eradicate needle-sharing infections
from Newswise (press release)
Switching the type of syringe used by people who inject drugs could help curb HIV transmission in countries with injection-driven epidemics within eight years, according to a new article by researchers at RTI International and the Futures Institute. Previous research has shown that so-called low dead-space syringes, which contain little residual blood, would dramatically cut HIV infection rates among injecting drug users.
New warnings over a rise in counterfeit condoms
from BBC Newsbeat
The UK government's health regulator has warned there are a rising number of counterfeit condoms being smuggled into the country. The Medicines and Healthcare products Regulation Agency (MHRA) claims millions have been illegally imported in the last 18 months. Family planning experts say the counterfeit condoms provide little protection against STIs or pregnancy. Tests carried out on many of the fakes show they have a high burst rate.