Real-world evidence of treatment reducing heterosexual transmission
The data are notable in that they do not come from the somewhat idealised conditions of a clinical trial, but from national databases monitoring the provision of treatment in China. Just under 39,000 heterosexual serodiscordant couples were included, and split into two groups for analysis – those who took treatment (usually because of a CD4 cell count below 350) and those who never took treatment.
In the treated group, there were 1.3 infections per 100 person-years, compared to 2.6 per 100 person-years in the non-treated group. After adjustment for confounding factors that had been recorded, this translated to a statistically significant 26% reduction in the risk of transmission.
This is much lower than the 96% reduction in risk seen in the HPTN 052 trial, and may reflect what is possible in ‘real-world’ conditions in a middle-income country. Specifically, adherence to therapy may be poor and Chinese patients often have to continue taking first-line therapies to which they have developed resistance. Moreover, the authors could not check that an individual’s infection was genetically linked to that of their primary partner.
While the reduction was statistically significant in the first year of follow-up, it ceased to be in subsequent years (although few couples were in the study for more than two years). The authors recommend that future studies examine how durable the reduction in risk is over time.
Comment: Although the reduction in the number of transmissions is lower than might be hoped, the study sheds light on what can happen in real-world conditions in which clinical care is less than ideal. Despite this fact, treatment reduced the number of infections by a quarter.
Half of HIV-positive gay men don’t believe treatment reduces infectiousness
Although the survey found that only 15% of men had recently had unprotected sex with someone of negative or unknown HIV status (serodiscordant unprotected anal intercourse or sdUAI), it discovered that the minority of men who were not taking antiretroviral therapy (ART) were more likely to have sdUAI than men taking ART.
Results also suggest some men are taking their viral load into account when making decisions about unprotected sex, with those with a detectable viral load considerably less likely to have sdUAI.
The survey found that beliefs about viral load and infectiousness influenced safer-sex decisions, with men who did not believe that viral load reduces infectiousness being less than half as likely to have sdUAI as men who believed that it did.
The men were asked whether they agreed with two statements: “When a viral load is undetectable, condoms are not needed to prevent HIV transmission” and “Undetectable viral load makes someone less infectious to a sexual partner”. Only 4% agreed with the first statement; 48% agreed with the second, leaving another 48% who agreed with neither.
Comment: As the researchers comment, these findings have implications for prevention strategies, particularly in terms of the complex question of whether making people aware of the benefits of treatment as prevention may have the unintended effect of increasing risk behaviour.
Very high rates of HIV infection among young US gay men
In 2009, 7% of people living with HIV in the US were under 24. The prevalence of undiagnosed HIV was higher than in any other age group, with 60% unaware of their infection
Of the 47,500 new HIV infections in 2010, 26% were in young people. Rates differed according to ethnicity and were highest among African Americans (57%). About three-quarters of new infections were attributed to sex between men.
The investigators also looked at HIV risk behaviours among high-school students. Of those who reported having sex, gay and bisexual males were more likely to report four or more partners and also reported high rates of injecting drug use (20%). Gay/bisexual males were significantly less likely to use condoms (44 vs 70%) and were less likely to report having been taught about HIV at school (75 vs 86%).
The overall prevalence of HIV testing among 18 to 24 year olds was 35%.
“More effort is needed to provide effective school- and community-based interventions to ensure all youths, particularly men who have sex with men, have the knowledge, skills and resources necessary to avoid HIV infection,” write the authors.
Comment: This study is worrying because it shows the rate of new infections in gay young people is far outstripping the overall rate, indicating the possibility of a renewed wave of infections.
Disappearing patients limit the proportion of people with HIV who are non-infectious
Estimates of the proportion of all people with HIV who are on ART and have an undetectable viral load range from 54% in the UK to as low as 25% among black gay men in the US.
In an Italian study, despite a high rate of diagnosis, people disappearing from care meant less than half of the HIV-positive population was likely to be on effective ART.
Of people diagnosed between 1996 and 2012, 92.6% returned for at least one appointment after diagnosis but over 20% disappeared from care. Of those who remained in care, 91% were on ART and of them 90% had a viral load below 50 copies/ml, meaning that between 60 and 65% of diagnosed people were on effective ART.
Researchers also estimate that at least 13% of the local HIV-positive population is undiagnosed.
People who left care were on average younger, more likely to be injecting drugs and less likely to be gay. But the biggest difference was that 50% of those who disappeared from care had not been born in Italy, versus 31% of those in care.
Comment: This study suggests that in European countries with good access to HIV treatment, one of the limiting factors on using ART to bring down the overall infection rate is the high mobility of people with HIV. A study from France came to the same conclusion. What studies of this type can’t find out, however, is whether these people are getting care somewhere else.
Sharing drug preparation equipment a potential source of hepatitis C transmission
Transmission of both HCV and HIV between injecting drug users (IDUs) has mainly been associated with the sharing of syringes. Needle and syringe exchange has been associated with a reduction of HIV and HCV incidence among IDUs.
However, sharing other injecting equipment persists, and this may explain continuing high rates of HCV transmission amongst IDUs.
The researchers looked at the persistence of HCV in water, filters and water containers.
At one dose, HCV could still be measured at infectious quantities after three weeks. A dose of one-tenth of a millilitre was no longer infectious after four days.
Even after discarding and refilling water from containers, the investigators found HCV-contaminated fluid in both plastic and aluminium containers.
Infectious quantities of virus were detectable in filters 24 and 48 hours after contamination with HCV.
The investigators conclude, “Prevention messages and campaigns should…notify people who inject drugs to the importance of eliminating all equipment-sharing practices, and supply of sterile equipment is recommended.”
Comment: This finding may indicate why HCV infection rates don’t go down as fast as HIV rates when needle and syringe exchange is introduced, though it may have relevance to residual transmission of HIV too.
Some women with HIV unaware that HIV treatment can protect their babies
An Italian paper suggests that some women with HIV may not have up-to-date information about reducing the risk of passing on HIV during pregnancy, birth and breastfeeding. One-fifth of women with HIV overestimated the likelihood of passing on HIV to their babies if they were on ART.
The study also showed that starting ART was associated with a decrease in reported desire to have a child and that fear of mother-to-baby transmission was the strongest predictor that a woman reported not wanting to have children.
The survey, conducted between November 2010 and February 2011, asked 178 women who were in a steady relationship whether they wanted a child.
Sixty-one per cent said no. This was more likely among the women who had an HIV-negative partner: whereas 44% of women with HIV-positive partners said they wanted a child, only 10% of women with HIV-negative partners did so.
Women were asked: “If all necessary measures were adopted, how likely do you think your child would be born without HIV?” Most women had a reasonably accurate view of this: 35% said they thought that it was a certainty that their child would be born without HIV and another 35% said the risk would be less than 5%. However, 9.4% thought the chance was over 50%.
Fearing they would not live long enough to raise a child and fear of having to disclose their own HIV status to their child were other reasons given for not wanting a child.
Comment: This study suggests that, among some women, exaggerated fears of infecting their child and their partner may be inhibiting them from becoming mothers.
Two-thirds of sexually active teenagers born with HIV have unsafe sex
A majority of sexually active adolescents who were born with HIV have had unprotected sex, US investigators have found. Many had a high viral load, potentially placing their partners at risk of infection.
“Sexual intercourse, while a normal developmental milestone, presents special challenges for PHIV+ (perinatal HIV-positive) youth,” comment the investigators.
A total of 330 people aged between 10 and 18 took part in the study. Three-quarters had a CD4 count above 500, but a relatively high proportion, 30%, had a viral load over 5000 copies/ml, meaning they were more than marginally infectious.
Overall, 28% reported having had anal or vaginal sex. Sexual intercourse was reported by 53% of 16 year olds and 87% of 18 year olds. A same-sex partner was reported by 13% of males and 21% of females.
Of those reporting sexual intercourse, 62% reported unprotected sex. Four male participants reported anal sex with a male partner; in three instances, this was unprotected.
Of the sexually active participants, 38 had a viral load above 5000 copies/ml and 30 were identified as having virus that was resistant to at least one antiretroviral.
The majority (82%) of participants reported knowing they were HIV positive when they first had sex. A third had disclosed their HIV status to their first sexual partner. The majority of individuals (84%) reported discussing condoms and condom use was more common in people who disclosed their HIV status.
Comment: Another study of US young people, but this time of those born with HIV. Negotiating sex is difficult for many teenagers, without the burden of disclosing HIV. These young people were laying themselves open to criminal prosecution in many US states, and would be in many European countries too. The study found that coming from a low-income family or not living with a birth parent was also associated with unprotected sex: we need studies in Europe to find out if the same risk factors apply to HIV-positive teens here.
Project focus - Introduction of new advocacy strategies on HIV prevention in Armenia
Introduction of new advocacy strategies on HIV prevention in Armenia
From We for Civil Equality NGO
The Armenian organisation for people with HIV announces how a new EU-funded project among seven former Soviet countries will enable it to provide better accessibility for vulnerable groups and more support for community-based organisations. A recent consultation identified an urgent need for free hepatitis and STI treatment, rapid community-based HIV testing, addressing discrimination by healthcare institutions, and integrating services to transgender people.
Would you like your HIV prevention project’s work publicised through the HIV prevention news: Europe bulletin? If you issue a press release or announcement, send an email alerting us to it to info@nam.org.uk and we may include a link to it in the next bulletin.
Other recent news headlines
UK Health Protection Agency urges testing drive
The UK’s Health Protection Agency (HPA) issued its annual report last month, and drew particular attention to the need for improvement in HIV testing rates. It found that, although the number of new HIV diagnoses in total went down last year, they continued to increase in gay men; for the first time since 1999, there were more infections in gay men than heterosexual people.
Minority of UK men attend regularly
A study of a large patient database in the UK has found that only 44% of male patients have never had a gap of more than six months between CD4 and viral load measurements, and that this is more common in heterosexual men and younger men. Meanwhile a single-clinic study from the city of Leicester found that only 40% of its patients had been seen in the last six months. The majority had transferred to other clinics, but between 10% and 15% could not be traced.
Many recent mothers have a detectable viral load
A study from two London hospitals found that although the majority of women with HIV who gave birth there returned for care after giving birth, some did not return for one or two years and 37% had a viral load over 100 copies/ml when they did return. This study was done, in part, to inform discussions about the possibility of relaxing breastfeeding guidelines in the 2012 BHIVA guidelines on treatment for pregnant women; in the end these guidelines did not change their recommendation of total avoidance of breastfeeding.
Editors' picks from other sources
New HIV epidemic looms over Romania
from Inter Press Service
New HIV infections among Romanian drug users have grown exponentially over the past couple of years. International and national groups working for HIV prevention expect the emerging epidemic to expand in coming years, despite causes for the rise being relatively easy to pin down.
HIV and AIDS in the European Union, 2011
from Eurosurveillance
In 2011, a total of 28,038 new HIV diagnoses were reported by European Union and European Economic Area countries. The annual rate of HIV diagnoses does not show clear signs of decrease and HIV continues to be concentrated in selected populations such as men who have sex with men and injecting drug users, and a high proportion reported as late presenters. Despite effective and available antiretroviral treatment, the number of AIDS cases increased in a few countries.
HIV soars among Greece's drug users while programmes cut
from Bloomberg BusinessWeek
HIV infections among drug users in Greece jumped more than 20-fold in fewer than two years, fuelled by a lack of needle exchange and methadone programs, according to the European Centre for Disease Prevention and Control.
STI epidemic amongst gay men contributing to high rate of HIV transmission
from National AIDS Trust, UK
New figures from the UK Health Protection Agency reveal in 2011 over a fifth of gay men (21%) diagnosed with HIV were simultaneously diagnosed with an acute STI such as chlamydia and gonorrhoea. This compared with one in 25 heterosexual men and one in 30 heterosexual women.
Russia reports 12% rise in HIV
from BBC Health
The number of HIV cases in Russia was 12% higher in the first six months of 2012 than in the same period last year, government health experts say.