News and upcoming events
Small Media - what is in the bars and how to get more information about it:
Need Help?
Need Help? (5th edition, striped cover) is an update of our pocket-sized guide to
everything that's gay in London. It's a complete listing of virtually all the help lines,
websites, and support organisations across the capital. It includes contact details for
gay youth groups in several different boroughs. There is a large section on sexual health
clinics, divided up by location (so you can find the one nearest you), clinics that offer
gay-specific services and ones that offer 1-hour HIV testing. You will also find
contact details of support groups for HIV-positive men, victims of homophobic violence,
men who sell sex, and services for black and Asian men, as well as where to go for
counselling services and how to sign up for self-help workshops.
Camden Good Sexual Health Team small media resources
What do you do when you're Wasted? This is a new, mini version of Camden's
booklet about drugs, alcohol and how they affect the decisions gay
men make regarding their sexual health. A Little Bit Wasted looks at the
reasons why gay men use drugs and alcohol in the first place - and
gives practical advice on how to use them more safely or cut down. There is
information about which drugs don't mix together and why - and a section about
which HIV medications have negative interactions with recreational drugs. Wasted
includes advice for recreational drug and alcohol users on how to have safer sex
when high.
'Reasons To Be Tested' is a new mini booklet that explains why it's a good idea to
take a test and know your HIV status. It explains how, if you are HIV-positive,
your best chance of living a long and healthy life lies in knowing your status.
Once diagnosed, you will be able to get the medical, practical and emotional
help that you need.
Other small media resources for gay men.
Upcoming Courses & Workshops for gay men:
Workshops and courses in October and November are:
GMFA Courses
If you want to stop smoking then our seven session Stop Smoking course for gay men can help. Evidence shows that the support you get from a Stop Smoking course, combined with the relief from withdrawal symptoms that Nicotine Replacement Therapy gives you, makes your attempt to quit ten times more likely to succeed than if you use willpower alone.
For information about course dates or to book a place, please visit www.gmfa.org.uk/stopsmoking.
PACE Workshops
Out of Control? - is a weekend for gay men who are unhappy about the amount or kind of sex they are having.
Begins 6.30pm Friday 7 November. Continues Saturday 8 and Sunday 9 November.
Risky Business - is a weekly on-going group where you will be able to share and talk about your experience with other gay/bi men, gain insight and make changes in your life. This group is for you if you find it a challenge to maintain safer sex, if your sex life feels out of control or if you have recently been prescribed PEP or used PEP in the past.
Every Tuesday at 6.30pm until until 16th December.
The Black Connection - is a monthly group for black men who have sex with men, to meet, talk & socialise as well as explore themes that will help celebrate the diverse community, relationships and lifestyles of Black men who love men.
The third Sunday of the month, 6 till 9pm. Next date: 16th November.
TwentySomething - is a relaxed and friendly monthly social and support group for gay and bi men in their 20s enabling them to meet others, talk about issues that matter to them and have fun. Monthly events will include discussions and workshops on all aspects of gay life including sex, relationships, coming-out, self esteem and assertiveness.
The third Monday of the month from 6.15pm till 9.15pm. Next date: Monday, 17th November 2008.
When Positive Meets Negative - is a monthly space for positive men to talk and engage in a new kind of positive community. This isn't a space for invited speakers and dead end conversations, but for connection, honesty, laughter and exploration.
Begins 6.30pm Friday 28th November. Continues Saturday 29th and Sunday 30th November.
Positive Hub - is a monthly space for positive men to talk and engage in a new kind of positive community. This isn't a space for invited speakers and dead end conversations, but for connection, honesty, laughter and exploration.
The last Sunday of the month from 6 till 9pm. Next date: 30th November.
To book a place or for more information call 020 7700 1323.
THT Courses
Mind Your Backs Guys! All you'll ever need to know about your arse and his
Ever been curious about prostates, the male G-spot, buttock exercising or douching? Whether you want to learn more about how to enjoy anal sex or have questions about the health of your posterior, this group is for you.
Thursday 20th November and every third Thursday of the month from 6pm to 9pm.
Book a place on 'Mind Your Backs Guys!'
Positively drug fucked
Are you HIV positive and been so 'out of it' that you've forgotten to take your pills or not taken them like you should? Would you like to know more about the impact that the recreational drugs you are taking are having on the virus. This group will guide you through the drugs that are out there, the impact that they can have on you, your meds, the virus and give you the information to help you make the right choice.
Saturday 22nd November and every fourth Saturday of the month from 10am to 12.30pm.
Book a place on 'Positively drug fucked'
How not to pick up
Have you ever found yourself with more than a phone number as a memory of that night of fun? Many of us will get a sexually transmitted infection at some time, even if we have safe sex or sex with only a few men. "How not to pick up" is a gay men's group which will guide you through what's out there, how to avoid it and what to do if you do "pick up".
Thursday 27th November and every fourth Thursday of the month from 6pm to 9pm.
Book a place on 'How not to pick up'
Other courses
Recently Diagnosed Course - held four times a year, this is a structured course open to anyone newly diagnosed in London who would like to be better informed.
To access this course, call Simon Johnson on 020 7812 1777 during office hours from Monday to Friday.
Living with HIV in Tower Hamlets - this course is for you if you want to know more about sex, intimacy and status disclosure, dealing with medication, coping with frustration, fatigue and isolation, and moving forward with your life.
Whether you are recently diagnosed or have been living with HIV/AIDS for some time you will find this course helpful and fun!
For more information on the next available course, please call Simon on 020 8694 9988 ext 208 or email epp@thepositiveplace.org.uk
Support Groups
The Midweek Group
Thanks to sponsorship from The Eddie Surman Trust (020 7738 6893) and the hospitality of South Central pub in Vauxhall, 'The Midweek Group', formerly supported by the UKC, continues to meet, socialise and have speakers on a regular basis (Tuesdays 6 - 9pm). Anyone interested in joining the group can come along on a Tuesday to enquire about membership.
Support groups for gay men from THT
Newly Diagnosed Gay Men's Group which meets twice a month at a Soho location, a support group for gay men diagnosed within the last year in London.
Gay Men's HIV Support Group which meets each Monday evening at a Soho location, for longer term diagnosed gay men in London.
Negative Partners Group which meets the last Thursday of the month at THT on Gray's Inn Road, open to the negative partner in a serodiscordant relationship.
In the autumn THT will be starting a Sex Addiction Support Group facilitated by their new addictions counsellor.
To access any of the above support groups, please call Simon Johnson on 020 7812 1777 during office hours from Monday to Friday.
Helplines
London Lesbian & Gay Switchboard - 020 7837 7324
LLGS normal opening helpline hours are 10am to 11pm daily.
THT Gay Men's Sexual Health Helpline - 020 7998 4161
This is a new helpline to give, information, advice and support about sexual health to gay men in London, whether they have HIV or not.
Broken Rainbow
The Broken Rainbow LGBT Domestic Violence Helpline is now open during the hours outlined below. The Helpline has recently partnered with London Lesbian & Gay Switchboard to provide an improved service to the Lesbian Gay Bisexual and Transgender community specifically. The helpline is staffed by LGBT people and offers a confidential service, across the UK, and supports LGBT individuals, family, and friends experiencing domestic violence. They also take calls from agencies seeking information and advice.
The Broken Rainbow LGBT Domestic Violence Helpline is open on: Mondays and Thursdays from 2pm to 8pm; Wednesdays 10am till 1pm. The Helpline number is 08452 60 44 60.
Further information is also available via their website: www.broken-rainbow.org.uk.
HIV treatment and health information
Terrence Higgins Trust and NAM are working together to provide face to face, printed and on-line treatment and health information for people living with HIV in London.
HIV Health Support Service
The HIV Health Support Service will be useful if you have just been diagnosed with HIV, or if you are thinking of starting treatment, changing treatment or experiencing side effects. Your local health trainer can help you gain more knowledge about anti-HIV drugs and how the virus affects your body. They can also help you make changes so you can lead a healthier life.
The service is available across the capital in clinics, at HIV and other community organisations, and if necessary at home. If you prefer you could meet other people with HIV by attending a group health skills session. To find out more information or to make an appointment with your local health trainer call 020 7737 9740.
Publications
NAM and THT’s treatment and health publications are pitched at different levels to suit different people’s needs.
The publications are:
- a summary resource setting out the ten most important things it is good to know about HIV and its treatment;
- over 100 factsheets on specific health issues;
- a range of entry-level booklets, covering broad topics. These may be particularly helpful if you are newly diagnosed. Click for an example of a booklet called Your Treatment;
- a range of booklets on specific treatment and health topics, providing more detailed information;
- a monthly newsletter: HIV Treatment Update;
- a comprehensive directory of symptoms, illnesses, treatments and side-effects;
- a treatments information website.
All printed resources are available free of charge to anyone living with HIV in London. Simply call 020 7840 0050 or e-mail info@nam.org.uk
FS magazine
The summer 2008 issue of FS is now available online and in bars and clubs across
London. You can download the pdf of the current issue by clicking on the image on the
right. Download pdf's of previous issues of FS from the
website.
Issue magazine
The latest edition of 'Issue', the magazine of HIV and sexual health sector development,
has been published. Copies can be obtained by emailing Andie Dyer at
andie.dyer@tht.org.uk.
U+ magazine
Terrence Higgins Trust have launched a new magazine for gay men with HIV. U+ presents
health information in an easy to read magazine format, with a mix of articles, interviews
and quizzes, as well as a problem page.
Each issue focuses on a particular theme. Issue three (out now) is about sex for gay men with HIV – dealing with HIV treatment, who's who at your clinic, other ways to look after your body and mind. Click on the image to download a copy from this website.
If you distribute health promotion resources to gay venues in your area, we would particularly encourage you to help us make U+ available on the commercial gay scene.
To order free copies for your organisation, please contact healthpromotion@tht.org.ukMass Media - what is in the press and how to get more information about it:
GMFA's Arse Facts Campaign:
It's tricky getting to know your arse; it's not something you look at everyday.
But whether you're a top, bottom or flip both ways, there are a few essential
facts that you should know to help keep you and your partners safe and healthy.
After reading the facts, why not
enter The Arse Factor for a chance to
win £100 of underwear or swimwear.
For more information contact rob.dawson@gmfa.org.uk
THT's Biology of Transmission Pt 2:
On the 17th December THT launches the new CHAPS national campaign
'Biology of Transmission Pt 2' which aims to alert gay men to the added risk of
using nitrite inhalents (commonly known as 'poppers') when being the receptive
partner during UAI.
The programme of work will be lead by a mass media campaign in gay publications from 19/12 until mid-February and will be supported by a website www.chapsonline.org.uk/biology; a new booklet 'Ready for action' which details how HIV is passed and how to reduce the risk; Exposed! 11, and a CHAPS Poppers Sector Summary Report.
For more information on the campaign and materials contact campbell.parker@tht.org.uk
Counselling waiting times & information:
Free Counselling Service from The GMI Partnership
The new GMI Partnership Counselling Service offers talking therapies which are designed to assist men who have sex with men:
- identify their risk factors for unsafe sex
- reflect on the issues and challenges in practising safer sex
- set goals and plan and implement strategies for reducing or eliminating risk.
This service is open to all men who have sex with men, without charge and regardless of HIV status, who have concerns with adopting or maintaining safer sex and HIV risk reduction behaviour. All men entering the Service will be offered a confidential assessment, and through a process of discussion will be able to identify the most appropriate talking therapy for them. These include:
- Cognitive Behavioural Therapy
- Peer mentoring
- Other forms of counselling
For further information or to make an assessment appointment please call 020 8305 5002 or email info@gmipartnership.org.uk.
Healthy Gay Living Counselling @ THT
THT now have a dedicated substance misuse and addictions counsellor within the well-being team offering a One-2-One service to gay and bisexual men. It may well be that you do not want to talk to friends or family about your concerns so if you are worried or anxious about the drugs you take, then this counselling resource may be able to help. So if your relationship with drugs is having a negative impact on other areas of your life, feels out of control or you are using drugs in combination and don't know what the consequences might be, feel free to call us with your concerns. You can arrange an assessment by calling the Wellbeing Service on 020 7812 1777 and speak with either Simon or Jason.
Also appointed is a specialist young person's counsellor working with young men living, working or studying in the borough of Southwark. To access this service you need to be male, aged between 16 and 24 and either gay, bisexual or questioning your sexuality. There is currently no waiting time for this service.
Languages we can provided counselling in are: English, French, German, Portuguese, Spanish, Italian, Yoruba, Luganda, Shona. Counselling is available for couples and individuals at sites across London, with appointments available in the evenings or on Saturdays, as well as during the day.
To book an appointment call Simon Johnson on 020 7812 1777 - Office hours are 9.30am to 5.30pm
Volunteers needed
The Gay Men's Interactions Partnership has exciting new opportunities for volunteer peer mentors, counsellors and health trainers. For more information click on the image to view the full advert, call 020 8583 2404 or email volunteering@gmipartnership.org.uk
Sector Information
Resources from THT
Healthy Respect
The Healthy Respect web pages give advice and information for people who have experienced problems with their healthcare because of their HIV status. Problems with GPs, dentists and other healthcare professionals are highlighted and solutions are offered. For more information, visit www.tht.org.uk/healthyrespect
GPs and Gay Men (CHAPS)
This programme of work has launched with the aim of providing gay and bisexual men with information which will enable them to have a better understanding of how the healthcare system works and why being gay or bisexual is important to their health care.
The programme includes a website for gay men including issues such as how the health
system works, what it can do and how being gay might effect your health and healthcare.
This can be found at
http://gpsandgaymen.chapsonline.org.uk
The website also contain a health professionals’ section containing extra
resources to ensure their services are meeting the needs of their gay and bisexual
patients.
A booklet accompanying this site, ‘GP treatment for gay and bisexual men’ is also available by contacting James Glavin at james.glavin@tht.org.uk or can be ordered individually by calling THT Direct 0845 12 21 200.
Your next steps
This booklet is for you if you’ve just found out you have HIV. You might also find it helpful if you’ve known for a while, but have not wanted to think about it much until now.
The booklet covers things that we often want to know about at this time.
There’s straightforward information about what HIV is and how we can
look after our health. The booklet talks about having sex when you have HIV,
and whether or not it’s a good idea to share your news with other people.
‘Your next steps’ is available by contacting James Glavin at james.glavin@tht.org.uk or can be ordered individually by calling THT Direct 0845 12 21 200.
Other Services or events of interest to gay men in London.
Living Well
Living Well is an NHS funded programme and is one of the core healthcare initiatives being offered to people living with HIV across London. Living Well provides a wide range of options that are intended to promote long-term life skills, encourage the development of a supportive social community and empower participants with the ability to self manage their condition and work in partnership with their health care professionals.
Options provided are:
Positive Self Management Programme (PSMP)
One of the first steps for those who join Living Well is the Positive Self-Management Programme; better known as the PSMP. The PSMP is run by trained facilitators, some of whom are living with HIV themselves, and consists of seven weekly sessions of two and a half hours each and an optional residential weekend. Some of the areas covered include:
- Goal setting
- Action planning
- Problem solving
- Coping Skills
- Support and information
- Planning for the future
The PSMP is delivered in a supportive group environment. Through discussion and sharing of information participants are encouraged to attain new skills and direction to help them make better informed decision about managing their condition.
The PSMP allows participants to meet other people facing similar concerns and challenges, helping them to overcome isolation and build a supportive social network.
Non-residential Weekend
Participants who have completed the PSMP are invited to attend an optional residential weekend. This is an opportunity to engage in workshops that will encourage a deeper experience and exploration of some of the issues and topics raised throughout the seven week programme
Facilitator Training
Training is offered to participants who have completed the PSMP and wish to become tutors, delivering the PSMP to their peers. Training is delivered under assessed conditions under license of Stanford University.
Life-Coaching
Twelve one-to-one sessions are offered with a qualified coaching psychologist. Coaching is suitable for clients who are keen to work strategically towards achieving future goals.
Counselling
Hour long sessions with a Living Well counsellor. These sessions are suitable for clients who are dealing with emotional issues which are usually related to their HIV status.
Positive East
The Gay Men's Team at Positive East offers a comprehensive range of services for gay men and men who have sex with men who are positive, negative or untested, who live or work in East London. For details visit www.gaymenswellbeing.com, email us at gaymen@positiveeast.org.uk or telephone Positive East on 020 7791 2855.
Himat, a group for South Asian gay, bisexual and men who have sex with men exploring issues of sexuality, culture, religion and race. For many South Asian gay men in London, facing up to being different can be full of unique problems. Being a minority within a minority can create a strong sense of isolation from other gay men. For details on Himat visit www.gaymenswellbeing.com or call on 020 7791 2855.
Positive Life is an activities group for HIV positive gay and bisexual men. The groups main aims are to offer a non-scene space for gay and bisexual men to meet and discuss topics of interest; to make friends with other positive gay men; be able to share experiences and where they can give and/or receive support, as well as an opportunity to learn new skills. For details on Positive Life go to www.gaymenswellbeing.com email positivelife@positiveeast.co.uk or call on 020 7791 2855
Signpost, a confidential telephone helpline for men who have sex with men provides basic information and guidance on sexual health, HIV/STI's as well as accessing services and groups across east London. Signpost operates every Tuesday and Thursday from 6.30 to 8.30pm on 020 7790 5795. For details on Signpost visit www.gaymenswellbeing.com
Advice services for Homeless LGBT people across London are saved and will expand
Stonewall Housing is delighted to announce that its vital advice service for
LGBT Londoners has been secured, due to new funding from London Councils. This
means that lesbian, gay, bisexual and transgender people who are homeless or
experiencing housing crisis will be able to access specialist, expert advice
from Stonewall Housing until 2012.
Anyone who is homeless or has a housing problem and needs advice can call the advice line: 020 7359 5767. www.stonewallhousing.org.
Interesting articles and news from around the world:
Start treatment at CD4 cell counts above 350, says large cohort study
According to an analysis of data from a very large North American cohort collaboration, starting antiretroviral therapy at a CD4 cell count between 351-500 cells/mm 3 results in a better likelihood of survival. The results were presented to the 48 th Interscience Conference on Antimicrobial Agents and Chemotherapy in Washington DC on Sunday by lead investigator Mari M Kitihata, on behalf of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).
The best time to start HIV treatment is not known. The current recommendation in Europe is that antiretroviral therapy should be started when a patient’s CD4 cell count falls below 350 cells/mm 3. A substantial body of evidence now supports this recommendation, but there is less information about the potential risks and benefits of starting treatment at a CD4 count above 350 cells/mm 3.
An analysis of European and North American cohorts presented earlier this year showed a higher risk of death among HIV-positive people with CD4 counts above 350 cells/mm 3 compared to the HIV-negative population, but this difference was non-significant among men who have sex with men.
To examine the effects of starting treatment at higher CD4 cell counts, a team of US and Canadian investigators pooled patient data from 22 US and Canadian HIV cohorts. This study was designed to "mimic, using observational data, what would be observed in a clinical trial enrolling asymptomatic [HIV-positive] individuals with a CD4 cell count of 351-500 cells/mm 3.”
The pooled cohort contained data from the medical records of 8374 individuals receiving HIV care between 1996 (the year when effective HIV treatment first became widely available) and 2006 (for a total of 24994 person-years of follow-up). None of the cohort participants had had AIDS-related illnesses, all were antiretroviral- naïve, and all had a CD4 cell count between 351 and 500 cells/mm 3.
The investigators compared the risk of death (from any cause) for patients who started treatment when their CD4 cell count was between 351 and 500 cells/mm 3 to the risk seen in individuals who did not begin treatment until their CD4 cell count was lower than 351 cells/mm 3
A total of 2473 patients (30% of the cohort) started antiretroviral therapy when their CD4 cell count was between 351 and 500 cells/mm 3; the remaining 5901 patients deferred treatment until their CD4 cell count was 350 cells/mm 3 or lower.
Raw comparisons of mortality rates in the two groups appeared to indicate only a slight advantage for earlier treatment. However, this was based on the total time spent in follow-up, which factored in the time off treatment only for the deferred (later treatment) group and could not take into account any subsequent interruption of treatment in the early treatment group. This introduces a so-called "lead-time" bias which had to be corrected for. An adjusted analysis was performed which excluded data from patients who did not begin treatment within 1.5 years.
The adjusted figures showed that patients who deferred therapy until their CD4 cell count was 350 or lower had a 71% increased risk of death compared to those individuals who started treatment at higher CD4 cell counts (a relative hazard [RH] of 1.7, with a 95% confidence interval [CI] of 1.4 – 2.1). This difference was statistically significant (p < 0.001).
Nearly identical results were seen when the analysis was restricted to the 77% of participants for whom baseline viral load data were available. Viral load was, itself, not an independent predictor of mortality. The relative risk remained the same in people who were hepatitis C (HCV) positive, and in injection drug users.
This interpretation is based on what the investigators themselves describe as observational data that "mimics … what would be seen in a clinical trial", and note that "a randomized clinical trial will be necessary to confirm this finding and support changes to established treatment guidelines." It should also be noted that survival was the only outcome assessed in this study, which did not measure toxicities or any other long-term outcomes.
“Results from this large North American cohort collaboration support initiation of [antiretroviral therapy] at a CD4 of 351-500 cells/mm 3, an earlier stage of HIV disease than is currently recommended”, comment the investigators. A further analysis, of the outcomes of starting treatment at CD4 cell counts above 500 500 cells/mm 3, is also ongoing.
Reference
Kitahata M.M. et al. Initiating rather than deferring HAART at a CD4+ count between 351-500 cells/mm 3 is associated with improved survival. 48 th Intersciene Conference on Antimicrobial Agents and Chemotherapy, abstract H-896b, Washington, 2008.
Initial CD4 cell counts in new seroconverters have declined over time
CD4 cell counts and CD4 percentages measured soon after infection with HIV declined significantly between 1985 and 2001 in a large group of patients who had recently seroconverted, according to a retrospective analysis of patient records by Dr. Nina Crum- Cianflone and team at the AIDS Clinical Consortium, Bethesda. The downward trend in CD4 counts at seroconversion appears to have leveled off in more recent years.
This study set out to examine whether CD4 cell counts in people newly infected with HIV ( seroconverters) are changing over time. Any such trends could reflect long-range changes in the virulence of the virus. Very few studies have looked at this question, with conflicting results; one large-scale analysis of multiple cohorts from Europe, Australia and Canada (published in 2007) did find that early CD4 cell counts declined between 1985 and 2002.
This investigating team evaluated retrospective data from 1944 patients who seroconverted between the years 1985 and 2004. The participants were racially diverse, from differing geographic areas, antiretroviral naive, and had a CD4 cell count recorded within 6 months of their HIV diagnosis. The cohort was predominantly male. The mean age was 29 years. (Average age slowly increased over the time periods in the study, from 27 years to 30 years; this was controlled for in the results.)
Seroconversion was documented by consecutive HIV-negative and HIV-positive tests. For the majority of participants, the time at which they seroconverted could be determined within two years. The majority of participants (92%) had their first CD4 measurement within 90 days of their HIV diagnosis.
The unadjusted average CD4 cell count for the period from 1985-1990 was 632 cells/mm 3, 555 cells/mm 3 for the interval 1991-1995, 495 for 1996-2001, and 499 for 2002-2004. The raw analysis, not adjusting for any other variables, found that the average post- seroconversion CD4 cell count decreased by 133 cells/mm 3 between 1985-1990 and 2002-2004.
In the full analysis, CD4 counts were adjusted for the period of uncertainty around the exact seroconversion date, the time from the HIV-positive test to the first CD4 cell count, age, gender, race, enrolment site, and viral load (in the 990 people for whom viral load data were available). This adjusted analysis found significant declines up until 2001 but not thereafter. Compared to the period 1985-1990, those who seroconverted in 1991-1995 had CD4 cell counts an average of 62 cells/mm 3 lower, and, in 1996-2001, 105 cells/mm 3 lower (p<0.0001 for all).
However, the decline from the period 1996-2001 to 2002-2004 was not significant (p=0.98).
Similar decreasing trends in CD4% and total lymphocyte count were noted, but not in CD8 cell count. Higher post- seroconversion CD4 cell counts were also associated with lower initial viral load, younger age, and white/non-Hispanic race.
The investigators concluded that a "significant decline in initial CD4 counts among seroconverters occurred during the first decade of the epidemic, with stabilization since the mid-1990s. Patterns of change in other immune cells such as the white blood cell count do not account for [this] decline. These data provide an important clinical correlate to studies suggesting that HIV may have adapted to the host, by HLA adaptation or CTL escape, resulting in a more virulent infection."
Reference
Crum- Cianflone NF. et al. Is HIV becoming more virulent? Initial CD4 cell counts among HIV seroconverters across the HIV epidemic: 1985-2007. 48 th Interscience Conference on Antimicrobial Agents and Chemotherapy, poster abstract H-4051, Washington DC, 2008.
MAINE: Forum Explores Aging with HIV/AIDS
The "graying" of the HIV/AIDS epidemic and how it is affecting Maine residents was the topic of a half-day conference Friday hosted by the University of Maine Center on Aging and the School of Social Work.
The matter becomes more relevant as more HIV/AIDS patients survive into their senior years, thanks to improved treatment options. While only about 20,000 AIDS patients were 50 or older in 1995, that number had grown to more than 120,000 by 2005, said Mark Brennan, senior researcher at the New York City-based AIDS Community Research Initiative of America and the conference's keynote speaker.
"When we ask [patients], 'who's going to take care of you,' they say, 'my friends will.' But more than half of their friends are infected, too," Brennan said. "And the long-term care environment is really not prepared to deal with this. It's going to be a real problem."
Brennan cited results from a recent study conducted by his organization showing that many HIV patients suffer from isolation and loneliness, especially as they age. Depression is commonplace among patients. Medical research has shown that HIV/AIDS is linked to earlier onset of such common age-related problems as high blood pressure, diabetes, arthritis, and cardiac conditions. High rates of current use of tobacco, alcohol, and drugs are common; even more patients are in recovery but experiencing the health consequences of earlier substance use, Brennan said.
Next, four local people offered their own reflections. One, social worker Latona Torrey, noted that the epidemic had fostered two important social trends: men providing end-of- life care for their partners and friends, and the development of long-term relationships between HIV-positive patients and their physicians.
Ron King, a retired AIDS program coordinator who is living with HIV, said anti-gay stigma remains a serious barrier to early testing and treatment. HIV, he said, "potentially doubles the discrimination" already facing older Americans.
Jury still out on whether circumcision protects gay men against HIV
A meta-analysis of studies of circumcision in gay men and men who have sex with men (MSM) has not found sufficient evidence to show that being circumcised reduced their risk of acquiring HIV. Although it finds a small reduction in the risk of HIV infection in circumcised men, this is not statistically significant - in other words it could just be a chance finding. Furthermore, the study, published in the Journal of the American Medical Association, found that although circumcised men who were exclusively insertive for anal sex had a lower risk of infection with HIV, the difference with uncircumcised men was still not statistically significant and could have been chance.
But the researchers did find that studies conducted before the introduction of effective HIV therapy showed a statistically significant association between circumcision and lower HIV risk. They also found that studies that were conducted more rigorously were more likely to find that circumcision had a protective effect.
The meta-analysis, by Gregorio Millett and colleagues from the US Centers for Disease Control, covered 17 studies conducted between 1989 and 2007. The analysis also included some unpublished results. The studies included 27,816 circumcised and 25,751 uncircumcised men (52% circumcised). Nine were conducted in North America while four out of the other eight were conducted in developing countries in Asia and South America. Circumcision prevalence in individual studies varied from 4% to 88% but the proportion of men circumcised did not appear to affect results.
Six studies also looked at the relationship between circumcision and other sexually transmitted infections ( STIs) and one looked only at other STIs and not HIV.
HIV prevalence in individual studies ranged from 5% to 72% and in the three studies that were able to report HIV incidence – the rate of new infections - it ranged from 0.8% to 2.8% a year.
Overall the studies produced a non-statistically-significant reduction of 14% in HIV infection. A subset of studies that looked at results in 2238 men who only had insertive sex found a 29% reduction in HIV infection among circumcised men, but this difference was also not statistically significant.
However, in studies conducted prior to the introduction of effective HIV treatment, the authors found a 53% reduction in HIV infection in circumcised men. The authors point out that this reduction is “comparable” to that seen in the randomised controlled trials of circumcision in heterosexual men. In contrast there is no association whatsoever between circumcision and HIV in more-recent studies. The authors also found a non-statistically-significant reduction of 51% in HIV infections in circumcised men in studies conducted in developing countries, where antiretroviral therapy is less available.
The authors suggest that higher rates of unsafe sex and resultant HIV and STI infection in gay men since HIV treatment became available may have obscured the relatively small benefit of circumcision.
They also found a trend to more statistically significant results as study quality increases, with a non-significant 32% reduction in HIV infection in circumcised men seen in studies where circumcision and HIV infection were confirmed by genital examination and testing.
Finally, the authors found no association between circumcision and reductions in any other STI. Indeed in post-1996 studies and in higher-quality studies, there was a nearly significant increase in HIV infection in circumcised men.
The investigators suggest that studies could be conducted in men who primarily have insertive sex or in resource-poor settings, though there would be considerable ethical issues in the latter case.
In a separate editorial, Sten Vermund and Han-Zhu Qian of the Institute of Global Health urge further trials to settle the question of whether circumcision offers any protection against HIV to gay men once and for all. They comment that “only further research can answer…the question as to whether MSM should be circumcised to reduce their HIV risk.”
However they also express concerns that such research might face opposition.
“The meta-analysis”, they say, “is likely to be used by both advocates and detractors of clinical trial investment; some will argue that the likely benefit is too modest to justify a multimillion dollar trial while others will argue that only a clinical trial will answer this important HIV prevention question.”
References
Millett G et al. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. Journal of the American Medical Association 300(14):1674-1684, 2008.
Vermund SH and Qian HZ Circumcision and HIV prevention among men who have sex with men: no final word. Journal of the American Medical Association 300(14):1698-1700, 2008.
Unsuccessful post-exposure prophylaxis may still result in weaker HIV infection and lower viral load
HIV post-exposure prophylaxis, even when it fails to prevent infection, may still have benefits, a case report in the Journal of Acquired Immune Deficiency Syndromes suggests.
The case report involved a patient who received post-exposure prophylaxis (often called PEP) with Truvada (FTC and tenofovir). Although this treatment failed to prevent HIV infection, the patient did have a well-preserved immune function and a lower viral load than would be expected. He was therefore much less infectious than the average patient during acute infection.
The patient was a 38-year-old gay man in New York, who first came to a clinic on 26 September 2006 reporting that he had had unprotected receptive anal sex with multiple partners during the previous 48 hours. He was treated with Truvada as post-exposure prophylaxis. During the period on this treatment, on 24 October, he reported more episodes of risky sex and his course of post-exposure prophylaxis was therefore extended. He stopped taking it on 7 November. He tested HIV-negative on that date.
He reported a third episode of risky sex on 28 November and was restarted on Truvada. On 18 December, three weeks later, he tested HIV-positive. He was adamant that he had had no risky sex during the period when he was not taking post-exposure prophylaxis, which he finally stopped taking on 29 December.
His first two viral load tests were performed on 22 December – when he was still receiving treatment with Truvada – and on 9 January 2007. His viral load was very low, with 213 and 647 copies/ml in these two tests respectively. His viral load increased after this but never exceeded 3500. His CD4 count was a very high 1800 cells/mm 3 on 22 December, just after his first positive HIV antibody test, and then fell to about 750. At no time did he have the high viral load and low CD4 count typical of acute HIV infection, and he had no HIV seroconversion symptoms.
The patient's antibody response developed much more slowly than normal. Some basic tests were performed on his HLA genes, which determine susceptibility to HIV infection, but he had no genetic mutations associated with a lower viral load or less virulent course of HIV infection.
Samples were taken of his intestinal mucosa and further tests were performed on the T-cells in his gut lining. These showed a third of the T-cells in his intestinal lymphoid tissue were CD4 cells. This is a lower proportion than in HIV-negative individuals (typically 56%), but twice as many as in subjects with acute HIV infection (16%). He also had considerably fewer activated CD4 and CD8 cells than the average person with acute infection, indicating a much lower level of generalised immune activation and gut inflammation.
One theory of how HIV causes AIDS is that the initial destruction of CD4 cells and immune hyperactivation in the gut, from which the body never completely recovers even under HIV therapy, eventually depletes the immune system. A better-preserved gut immune system may therefore lead to slower progression to AIDS – as does a lower viral load.
Encouragingly, despite the patient contracting HIV while taking Truvada, there was no evidence of resistance to either FTC or tenofovir, even using the most sensitive resistance tests.
The authors write that the patient’s HIV infection was more attenuated (weaker) than usual and that this was probably related to the antiretroviral therapy he was taking.
They add that the findings of lower viral load and CD4 cell depletion could “have a very beneficial effect on the spread of infection…and likely reduce the probability of subsequent forward transmission".
They comment: “It is important to emphasise that this case report represents ‘real-world’ use of antiretroviral drugs to prevent infection. It is likely that even in the best of circumstances, adherence will be intermittent and patients will…stop and start from time to time based on behaviours and perceived risk as was the case here.”
They conclude that this cases strongly supports “continued investigation of the use of antiviral agents as a means to reduce HIV transmission” in a situation where “the prospect of an effective vaccine remains distant” and microbicides “have questionable applicability to MSM transmission.”
Reference
Prada N et al. Drug-susceptible HIV-1 infection despite intermittent fixed-dose combination tenofovir/emtricitabine as prophylaxis is associated with low-level viremia, delayed seroconversion, and an attenuated clinical course. Journal of Acquired Immune Deficiency Syndromes 49(2):117-122. 2008.
NETHERLANDS: Online-Mediated Syphilis Testing Shows Promise
Online-mediated syphilis testing is helping diagnose syphilis among men who have sex with men (MSM), a new report suggests.
The annual number of syphilis cases in Amsterdam increased from 35 to 240 between 1998 and 2004, according to Rik H. Koekenbier of GGD Amsterdam and colleagues. Infections among MSM amounted to 84 percent of new syphilis diagnoses in 2004.
The researchers developed a Web site that offered information about syphilis and motivated visitors to download a referral letter linking them to syphilis testing in a nonclinical setting. One week after undergoing a blood test, participants could view their results online. The researchers compared the percentage of syphilis-infected men detected online with those diagnosed at the local STD clinic during the same time period.
During 15 months, 898 site visitors downloaded referral letters, and 93 men (10 percent) were tested. The online results feature was used by 90 of the 93 men (96 percent). Of the 93 men tested, 14 (15 percent) had a positive test. Four of these did not confirm their results at the STD clinic. Of the 10 infected men who visited the STD clinic, three (33 percent) had never done so before. A "significantly higher percentage" of men needing treatment for syphilis were found through the Web site compared with the STD clinic (50 percent vs. 24 percent).
"Online-mediated testing for syphilis is feasible and was more successful in detecting [MSM] with an early or late syphilis infection than standard procedures," the authors concluded. "However, longer promotion periods are needed to generate more usage of the online service."
"The more people come in contact with online public health interventions, the better our chances are of improving the health of the population," said Koekenbier. "In this time where people receive and process information from different technical platforms such as mail, chat and Web sites, it becomes more important to be exposed on all these platforms."
The report, "Online-Mediated Syphilis Testing: Feasibility, Efficiency, and Usage," was published in Sexually Transmitted Diseases (2008 ;35(8):764-769).
Treating co-infections can lower HIV viral load, reducing risk of transmission and improving prognosis
Small declines in viral load achieved without anti-HIV drugs by treating infections can reduce the risk of heterosexual HIV transmission and HIV disease progression, according to a review article published in the October edition of AIDS. As almost three-quarters of HIV-infected individuals are not taking anti-HIV drugs the authors believe that treatment for infections could have an important impact on the epidemiology of HIV and the prognosis of HIV-positive patients.
Access to antiretroviral therapy in resource limited settings has expanded significantly in recent years. The overwhelming majority of HIV-positive individuals, however, are not yet in receipt of anti-HIV drugs due to reasons of access or because their the health of their immune system does not warrant such treatment.
There is therefore a need, argue the authors, for “cheap, implementable, and sustainable approaches” to prevent HIV transmission and to improve the prognosis of HIV-positive people not taking antiretroviral therapy.
Earlier studies have suggested that treating infections in people with HIV leads to a small, but sustained fall in viral load.
The authors wanted to establish if such modest falls in viral load (0.3 log 10 or 0.5 log 10) would have benefits for patients in terms of reducing the risk of HIV transmission or the risk of HIV disease progression.
A review was therefore conducted to identify studies conducted between 1987 and July 2008 that looked at the link between viral load in the blood and heterosexual HIV transmission. They also identified studies investigating the link between viral load and HIV disease progression. Models were then developed to estimate the effect on transmission and disease progression of increases in viral load of 0.3 log 10, 0.5 log 10 and 1.0 log 10.
After looking at four studies, the investigators found that the viral load of individuals who transmitted HIV and those who did not differed by between 0.6 – 1.0 log 10. These studies showed that a 0.3 log 10 increase in viral load increased the risk of HIV transmission by between 14% - 31%, that an increase of 0.5 log 10 would increase the risk by between 19% - 56% (40% average) and that an increase in viral load of 1 log 10 increased the risk of transmission by between 31% - 145% (100% average). Overall, the investigators calculated that each 0.3 log 10 increase in viral load reduced the risk of HIV transmission by 20%.
Five studies provided sufficient information for the investigators to estimate the effect of increases in viral load reduction on HIV disease progression. An increase in viral load of 0.3 log 10 increased the risk of progression to a new AIDS-defining illness or AIDS related death by between 14% - 36% (25% average), with a 0.5 log 10 increase in viral load increasing the risk of between 24% - 67% (44% average) and a 1 log 10 increment increasing the risk between 55% - 179% (average 113%) .
“Small reductions in viral load may have practical applications, even in the antiretroviral therapy era”, write the authors, “treatment of coinfections prevalent among HIV-infected persons in the developing world…may result in small sustained drops in plasma HIV RNA.” They note that mathematical models have shown that treatment of infections and nutritional support can reduce the risk of HIV transmission.
They conclude “small declines in viral load, when introduced on a mass scale, can reduce the likelihood of transmission and slow disease progression. In global efforts to provide antiretroviral therapy, good primary care and systematic control of opportunistic and other coinfections should not be neglected for HIV-infected persons as their treatment may provide a hitherto unanticipated HIV-associated boon.”
Reference
Modjarrad K. et al. Impact of small reductions in plasma HIV RNA levels on the risk of heterosexual transmission and disease progression. AIDS 22: 2179 – 2185, 2008.
Up to half of gay men diagnosed with HIV in UK may have been infected in previous year
About four in every ten gay men in the UK who have HIV are undiagnosed, the British HIV Association’s Autumn Conference heard on 10 October, for the most part because they don’t test often enough rather than because they refuse to test.
The conference also heard details of mathematical modelling which suggests that almost half of gay men in the UK diagnosed in 2008 are likely to have acquired HIV in the previous year.
One presenter suggested that clinics should recall gay men at least annually for an HIV test.
The conference also heard that an even higher proportion of Africans with HIV – over six in ten - are undiagnosed. The main reason for this is because they have not tested in their own country, often arrive with low CD4 counts and tend not to test till they get symptoms.
The last session of the autumn conference of the British HIV Association (BHIVA) was a joint symposium shared with the British Association for Sexual Health and HIV (BASHH) and sought to unravel the mystery of why so many people remain undiagnosed.
Professor Andrew Phillips of the Royal Free & University College Medical School in London outlined the problem. A recent survey (Williamson 2008) of men in gay venues in five UK cities (London, Brighton, Manchester, Glasgow and Edinburgh) had found that of the 9% who tested positive when their saliva was tested anonymously for HIV antibodies, 40% were unaware of their infection; of these, nearly two-thirds thought they were HIV-negative.
The last annual report by the Health Protection Agency on HIV diagnoses in the UK found that, paradoxically, although the proportion of gay men who take an HIV test when they go for a sexual health check has increased from 45% to 85% in the last ten years, the proportion who walk away with their HIV infection undiagnosed has only declined during the same time from 65% to 45%. This means that it is the gay men who are most likely to have HIV who are least likely to test.
Why is this? There are three possible explanations:
- Some gay men who say they are HIV negative and refuse a test actually know they have HIV and lie about it, possibly because they fear being stigmatised or even prosecuted if they reveal unsafe sex;
- A sub-population of gay men who are at high risk of HIV are so anxious about it that they actively avoid testing;
- HIV incidence (the new infection rate) among some gay men is so high that taking a test every few years is failing to detect recent infections.
Data that would prove which of these explanations is most pertinent are uanavailable, but Prof. Phillips said that a mathematical model which calculates the rates of new infection and new diagnoses in gay men suggests that the third factor is the predominant one. His model found that nearly half (46%) of gay men with HIV who have been diagnosed in 2008 would have been infected this year, and only 15% before 2004.
“People are not necessarily resistant to testing, they just need it frequently,” he said.
In contrast, 55% of undiagnosed Africans would have been infected before 2004, with diagnosis rates influenced more by the date of arrival in the UK than by the date of infection.
Phillips said the undiagnosed population was a dynamic group. A quarter of gay men infected with HIV in 2008 will have been diagnosed by the end of this year, as will 30% of infected heterosexual men and 40% of women. While only one in six gay men who get diagnosed will do so because they get symptoms caused by immunodeficiency, over 60% of heterosexual men will, because they are more likely to be diagnosed late in the course of their HIV infection.
Professor Graham Hart, Director for HIV and Sexual Health Research at University College London, told the conference that there was some evidence from a previous Scottish study, also by Williamson and colleagues (2007) to back up Phillips’s model. In this survey, 46% of gay men in Glasgow and Edinburgh had never tested for HIV and of those who had, half had not done so for more than a year. When asked why they had never tested, or not tested recently, the two most common reasons (respondents could choose more than one reason) were “I have not been at risk” (45-46% of both categories) and “I know my status” (a third of those who had never tested, and 40% who’d not tested for over a year).
Another common reason for not being tested was because men were in the “window period”, i.e. were turning up at a clinic within a month of a risk incident and thought that there was no point in getting tested. In the post-seminar discussion, an audience member commented that patients were unaware that the fourth-generation HIV tests recommended by the new BHIVA/BASHH Testing Guidelines, which include an antigen test, had shrunk the window period to as little as two weeks, and might be using it as an excuse not to get tested. Suggestions were made that clinics should revise their protocols so that patients presenting soon after exposure should be offered opt-out testing regardless and recalled a month later for a second test.
The fact that in the Scottish survey 56% of men who were in fact HIV-positive despite having had a previous negative test described themselves as “HIV negative” – more than the proportion who said “I don’t know”, underlined the idea that a lot of gay men feel that a negative test implies negativity for a long time to come, regardless of further risks.
However a large minority of men also expressed significant fears around testing, with about one in six of respondents saying they were “too frightened” to go for a test (or another test) and about one in nine saying they “didn’t want to know”.
So how do we reduce the proportion of people who are undiagnosed and shorten the interval between infection and diagnosis? Undiagnosed HIV may be due to high incidence but it’s also due to low rates of testing, with Hart pointing out that no more than two-thirds of UK gay men have had an HIV test compared with 92% in the USA and 96% in Australia.
The new BHIVA/BASHH Guidelines recommend an expansion of testing into primary care, with tests for anyone who presents with a list of indicator conditions, and routine screening in A&E departments and at GP registration for patients in Primary Care Trusts where HIV prevalence in the general population is over 0.2% (currently 21 PCTs fit this criterion).
Hart presented new results from a pilot study called Rapid HIV Assessment in Primary Care (RHIVA) in which all new patients aged 18-55 registering at one London GP surgery between October 2007 and March 2008 were routinely offered an OraQuick saliva HIV test. Out of 85 eligible patients, less than half (38) tested. Of the 55% who did not, just over a third said they had had a previous test, but the other two-thirds said they were “not at risk”.
Most participants were positive about the programme. One Nigerian man commented that “If you go to a GUM clinic you will be stigmatised, but with a GP no-one will know you’ve had a test. I have never, ever been offered an HIV test before.” However a minority of patients were worried that “it’s so quick – it could be a real shock” or that the test was “intrusive”.
Professor George Kinghorn of the Royal Hallamshire Hospital in Sheffield also emphasised the section of the new BHIVA/BASHH testing guidelines that say “any competent healthcare professional” should be able to do an HIV test.
He was critical of medical personnel who still do not think of testing despite symptoms suggestive of AIDS.
“These cases have been regarded as medically unfortunate,” he commented, “but in the future they may be regarded as medically negligent.”
While backing the guidelines’ recommendation for routine screening of patients in A&E and at GPs, he asked, “Why is it more acceptable to screen the asymptomatic than to do the obvious and test where symptoms indicate HIV?”
Dr Martin Fisher of Brighton and Sussex University Hospital highlighted a case he had presented the previous day, in which a 26 year old Spanish man presented with meningitis and fever but was not asked about sexual risks or tested for HIV, and was subsequently found to be the source partner of a man who tested HIV-positive a year later. The man concerned had tried to sue the hospital for not testing him, Dr Fisher noted.
Main references
Phillips A. Epidemiology of undiagnosed infection and its implications for onward transmission of HIV in the UK. Joint BHIVA/BASHH Ordinary General Meeting, BHIVA autumn conference, London. 2008.
Hart G. Why do some patients refuse HIV testing? Joint BHIVA/BASHH Ordinary General Meeting, BHIVA autumn conference, London. 2008.
Kinghorn G. How to reduce the prevalence of undiagnosed HIV infection outside the clinic. Joint BHIVA/BASHH Ordinary General Meeting, BHIVA autumn conference, London. 2008.
Other references
The UK Collaborative Group for HIV and STI Surveillance. Testing Times. HIV and other Sexually Transmitted Infections in the United Kingdom: 2007. London: Health Protection Agency, Centre for Infections. 2007.
Williamson LM et al. Sexual risk behaviour and knowledge of HIV status among community samples of gay men in the UK. AIDS 22(9): 1063-1070, 2008.
Williamson LM et al. HIV prevalence and undiagnosed infection among a community sample of gay men in Scotland. JAIDS 45(2):224-30. 2007.
UK conference discusses the `Swiss statement` on infectiousness of people on HIV treatment
There was broad consensus at last week’s autumn conference of the British HIV Association that effective HIV treatment significantly reduces the risk of HIV transmission. But nobody – even a leading proponent of what has become known as the `Swiss statement` – was prepared to say that HIV transmissions never occurred when an individual had an undetectable viral load.
In January this year leading Swiss HIV doctors issued a statement saying that HIV-positive individuals who were taking antiretroviral therapy with an undetectable viral load in their blood and no sexually transmitted infections could not pass on HIV to their sex partner. It quickly became known as the `Swiss statement` and has been hotly debated ever since, becoming one of the top subjects of this year’s International AIDS Conference in Mexico City.
A consensus quickly emerged that HIV treatment that suppresses viral load in the blood to undetectable levels does significantly reduce the risk of HIV transmission during unprotected sex. A dissenting voice, however, was raised by some Australian HIV doctors who developed a model that assumed that there was no lower limit below which HIV transmission could not occur. But an editorial which accompanied this paper rejected this methodology, the authors writing that denying the impact of HIV treatment on transmission risk was “dishonest and futile”.
The autumn meeting of the British HIV Association provided an opportunity for UK doctors, healthcare workers and community activists to discuss the science behind the `Swiss statement` and its impact on people living with the virus.
'Undetectable = uninfectious'
No new scientific information that has not already been extensively discussed in relation to the debate about 'undetectable = uninfectious' was presented. Prof. Bernard Hirschel of Geneva University Hospital briefly discussed the studies showing that patients with an undetectable viral load were not transmitting HIV.
He also presented a slide summarising a study conducted in Rwanda that showed that HIV treatment was much more effective at preventing HIV transmission than promotion of condoms. This study, presented to the International AIDS Conference in 2006 ( Kayitenkore K et al. 14th International AIDS Conference Toronto 2006, abstract no. MOKC101), showed that there were only 2 HIV transmissions in 248 serodiscordant couples where the HIV-positive partner was receiving HIV therapy (a transmission rate below 1%) compared to 40 transmissions (a transmission rate above 5%) in serodiscordant couples where the HIV-positive partner did not receive HIV treatment and who had condoms promoted to them. He therefore told the conference that data appeared to show that effective HIV treatment was more efficacious than condoms at preventing HIV transmission.
In support of the 'undetectable = uninfectious' argument, Prof. Hirschel also summarised studies showing the reduction in the risk of mother-to-child HIV transmission when a mother is taking HIV treatment and has an undetectable or very low viral load.
Nevertheless Prof. Hirschel conceded that in medicine you should “never say never” and also that the information to date was restricted to heterosexual couples.
HIV replication in sexual compartments
Dr Steve Taylor of the University of Birmingham presented information from a number of studies that have looked at HIV replication in the genital tracts of men and women who are taking HIV treatment.
A consistent pattern emerged in these studies. Men with an undetectable viral load almost always had undetectable HIV in their semen (although viral load could become detectable in semen if a sexually transmitted infection was present).
In women, however, studies have revealed a more complex picture with up to 30% of women continuing to shed HIV in their genitals despite having an undetectable viral load in their blood.
Dr Taylor suggested that localised HIV replication in the genital compartment during HIV therapy may in some circumstances lead to the development and potential transmission of drug resistant virus.
Dr Taylor also noted that there was very limited information on the effect of HIV treatment on viral load in the rectal mucosa. The one study that has explored this found that HIV was still detectable in this compartment in the presence of effective HIV treatment.
The community response – gay men
Edwin Bernard, editor of NAM ’s HIV Treatment Update (which has published three major articles in recent years looking at the impact of treatment on infectiousness) outlined community response (largely from gay men) to the `Swiss statement`.
He likened this response to the classic “grieving process” with individuals seeking to deny the Statement, reacting with anger, bargaining, becoming depressed about its implications, or accepting it.
He noted that for gay men, the statement resonates more strongly for men who have a problematic relationship with condoms, primarily because they perceive that sex without condoms provides greater intimacy.
He also said that an individual's relationship to risk and risk perception was also critical in their interpretation of the Statement. If successful treatment changes the definition of 'safer sex', then deciding how safe 'safer sex' actually is becomes a very personal, individualised decision.
Clinicians, as well as people with HIV and their sexual partners, require better skills to understand and assess the risks of sex compared with other risks in life, he concluded.
The community response – women
Silvia Petretti of Positively Women presented the results of consultation conducted with HIV-positive women about the Swiss statement. This revealed a range of responses with women seeing both pros and cons.
The perceived cons included a muddying of safer sex messages, and some women also noted that it could make negotiating safer sex harder. Concerns were also raised about the implications of chronic genital herpes. It was also suggested that the Statement could mean that sexual health is perceived only in terms of HIV transmission risk and there were questions about its implications for injecting drug users.
But the women consulted by Silvia Petretti also saw benefits in the `Swiss statement`. Some women said that the statement supported what they were already doing, and it was also suggested that an implication could be that it made conception easier. Other benefits included an incentive to maintain good adherence.
Stigma could also be reduced by the statement if people with HIV on treatment were no longer perceived as “vectors” of disease.
She noted, however, that many of the women consulted were unaware of the statement and contrasted this with the widespread knowledge about the studies suggesting that circumcision could reduce men’s risk of HIV. Of note, the protective effective of circumcision in these studies is at most 60%, much lower than the protective effective of treatment.
Wider UK responses
Only an hour was made available by the conference organisers for this session and there was little time for detailed discussion of the presentations or questions from the floor.
However, Prof. Hirschel noted that the small number of infections likely to occur from individuals with an undetectable viral load were of negligible public health significance compared to the large number of infections originating in undiagnosed individuals, a comment that was greeted with applause.
Prebiotics may improve gut health, immune system function, UK conference hears
A prebiotic supplement consisting of simple sugars produced from lactose, chicory, and citrus fruit has been found to improve gut health, which in turn significantly improved immune system function in a small study of treatment-naive HIV-positive individuals.
Early results of the pilot COPA trial were presented to the BHIVA Autumn Conference held last week in London by Dr Mario Clerici of the Milan University Medical School during a plenary session on gut immunity and HIV.
Dr Clerici began by explaining that the gut is the largest immune system organ in the human body. Soon after an individual becomes infected with HIV, the virus directly infects gut-associated lymphoid tissue (GALT), where between 70% and 80% of all immune cells exist, destroying a massive amount of CD4 cells – up to 80% within a month of infection.
It is now thought that these major changes seen in the gut following primary infection can greatly influence immune response. Two years ago, investigators from the United States discovered that leakage of microbes from the gut as a result of HIV-related damage to the gut wall may be one of the major causes of the systemic immune activation that drives the HIV disease process.
Earlier this year, investigators from the University of Minnesota linked the dramatic and enduring depletion of CD4 cells from the gut with the rapid and extensive deposition of collagen in the gut’s lymphatic tissue.
Furthermore, research from two teams, one at the University of California, and another at the US National Institutes of Health, found that HIV persists in gut CD4 cells even in the presence of effective antiretroviral therapy, resulting in a reservoir of infection that eludes current treatments.
The COPA trial
In order to understand better the relationship between HIV, the leaking of gut microbes, and its effect on the immune system, Dr Clerici and his colleagues at the University of Milan, as well as other colleagues in Italy and the Netherlands, have enrolled a cohort of 57 healthy, asymptomatic HIV-positive, antiretrovirus-naive individuals.
They first studied the effect of HIV infection on various ‘good’ and ‘bad’ microbes in the cohort’s gastrointestinal (GI) tracts and found a very high prevalence of the ‘bad’ microbes P. aeruginosa and C. albicans compared to levels reported for healthy individuals. On the other hand, they found very low levels of the ‘good’ bacteria, bifidobacteria and lactobacilli, compared to levels reported for the general population – less than half the average normal amounts of bifidobacteria, and only about 1 - 2% of the normal amounts of lactobacilli.
When they looked at faecal calprotectin – a marker of intestinal inflammation – half of the cohort had levels indicating inflammation, with a third indicating significant inflammation, similar that seen in inflammatory bowel disease. Since intestinal inflammation is known to reduce the intestinal barrier function, Dr Clerici argued that these data confirmed the breakdown of the intestinal barrier.
Once they had established that their cohort’s guts were not functioning well, Dr Clerici and his colleagues then attempted to come up with a solution – a way to improve gut health that they hoped would reduce inflammation and improve immune response.
They teamed up with the Danone Research Centre for Specialised Nutrition in the Netherlands to produce a unique prebiotic supplement, consisting of nine parts short-chain Galactooligosaccharides ( scGOS) from lactose; one part long-chain Fructooligosaccharides ( lcFOS) from chicory; and ten parts Acidic Oligosaccharides from pectin hydrolysate (AOS) from citrus fruit.
Prebiotics are non-digestible food ingredients that can selectively stimulate the growth or activity of ‘good’ and ‘bad’ bacteria in the colon. Probiotics, such as 'live' yoghurts and similar dairy products, work in a similar way, but in the small intestine.
The 57 individuals in the COPA trial cohort were randomised to receive either a single (15g/day) or double (30g/day) dose of the prebiotic supplement, or a placebo ( maltodextrin) for 12 weeks.
The prebiotic supplement was found to be safe and well-tolerated (side-effects can include gas and bloating) and although there was no major effect on absolute CD4 counts or on viral load, Dr Clerici’s team did measure significantly improved levels of ‘good’ bifidobacteria (after 12 weeks, levels increased to a median of 14.1% and 15.8% for single and double dose, respectively, compared to under 5% in the control group; p < 0.05) and significantly reduced levels of a cluster of Clostridium microbes, including C. perfringens and C. difficile (from 0.012% to undetectable in the double dose group; p = 0.009).
Most intriguing, however, were two slides at the end of Dr Clerici’s plenary showing the effect of the prebiotic supplement on immune activation in 20 of the participants in the COPA trial.
After twelve weeks, the double dose of prebiotics was found to have significantly reduced the number of activated CD4/CD25 T cells (p < 0.01) in the peripheral blood. Although the single dose also reduced immune activation, this was not statistically significant (p = 0.09), due to small numbers in the study.
Nevertheless, the single dose was found to have significantly increased natural killer (NK) cell activity (p < 0.001) in the peripheral blood. Although the double dose increased NK cell activity, again this was not statistically significant (p = 0.08) due to small study numbers.
Nevertheless, Dr Clerici ended his presentation by noting that this proof of concept study paved the way to enrolling larger studies into the effect of prebiotics on gut health, which may hold the key to further understanding – and possibly have a major effect on – the gut and HIV-related immune activation.
References
Clerici M. BHIVA Foundation Lecture: The role of the gut in HIV pathogenesis BHIVA Autumn Conference, London, October 2008. Gori A et al. Early impairment of gut function and gut flora supporting a role for alteration of gastrointestinal mucosa in Human Immunodeficiency Virus pathogenesis. J Clin Microbiol. 46(2): 757–758, 2008.
HIV-associated immunosuppression increases risk of liver cancer
Immune suppression caused by HIV increases the risk of liver cancer, say researchers with the Swiss HIV cohort. Their report, published in the October 18 th edition of AIDS, also suggests that the effect is most pronounced in the presence of hepatitis B virus infection. Liver cancer, they say, may become a significant issue in areas of the world where hepatitis B is endemic such as sub-Saharan Africa and Asia as lifesaving treatment allows people with HIV to live longer.
Deaths due to liver disease are becoming more common as people with HIV live longer thanks to antiretroviral therapy. Co-infection with hepatitis B or C virus is common among people with HIV, and there is evidence that co-infection with HIV and hepatitis B or hepatitis C increases the risk of cirrhosis and liver-related deaths.
However, there has been no clear evidence that HIV itself has an impact on the risk of liver cancer. A large 2001 study found that CD4 cell count at AIDS diagnosis did not predict cancer risk and suggested that the excess risk could be attributed to the high prevalence of hepatitis virus co-infection.
To further investigate the link between immune suppression and liver cancer, investigators undertook a case-control study using data from the Swiss HIV cohort. Investigators searched the cohort database for cases of liver cancer and identified 26 cases of hepatocellular carcinoma (HCC). For each patient, investigators then attempted to select ten matched control patients without cancer. They obtained a total of 251 controls.
When investigators compared markers of immune function between the two groups, they found that CD4 cell count taken within a year of diagnosis was associated with risk of liver cancer. Each 100 cells/mm 3 decrease was associated with a 33% increase in risk (odds ratio [OR] 1.33, 95% CI: 1.06 - 1.68). Compared to a CD4 cell count above 500 cells/mm 3, a CD4 cell count between 200 and 499 cells/mm 3 was associated with an OR of 5.32 (1.15 - 24.5), and a CD4 cell count below 200 cells/mm 3 was associated with an OR of 6.70 (1.24 - 36.1). Changes in CD4 cell percentage (OR for each 10% decrease 1.65, 1.01 - 2.71) and a history of AIDS (OR 2.40, 1.06 - 5. 44) were also associated with an increased risk of cancer.
The investigators state: “Our present nested case-control study showed, for the first time, a specific association between HCC risk and low CD4+ cell count in the year preceding hepatocellular carcinoma diagnosis. These findings, therefore, complement previous reports that declining CD4+ cell counts increase overall liver-related deaths, predominantly due to liver failure, among [people with HIV]”.
Several factors did not appear to be linked to cancer, including CD4 cell count at enrolment into the cohort, HIV viral load and history of antiretroviral use. The investigators suggest that this last finding speaks against the hypothesis that HIV treatment, which is known to be toxic to the liver, may hasten liver damage and increase the risk of cancer.
The investigators made another striking finding: all cases of cancer were associated with infection with either hepatitis B or hepatitis C. Of the 26 cases, ten were in people with hepatitis B infection, eleven were in people with hepatitis C infection, and five were in people with both infections. Moreover, infection by each virus fell clearly into HIV transmission categories. Among injecting drug users, 13 of 14 had hepatitis C virus infection, while among men who have sex with men (MSM) and heterosexuals, eleven of twelve had hepatitis B virus infection. There were no cases of cancer in the absence of hepatitis virus infection. This link between hepatitis virus infection and cancer remained unexplored because, as the investigators write, “matching for transmission category hampered us from evaluating the importance of hepatitis virus infections as independent risk factors for hepatocellular carcinoma”.
Investigators then looked at the impact of CD4 cell count on cancer risk in the two transmission populations. “The association between lower CD4 cell counts and HCC risk was also particularly strong for MSM/heterosexual/other and hence, due to the strong dichotomy mentioned above, for hepatitis B-related hepatocellular carcinoma.” In addition to corroborating evidence that hepatitis B virus worsens liver damage, especially at low CD4 cell counts, the investigators add that, “the hypothesis that immune suppression might actually reduce [ hepatocellular carcinoma] risk due to less immune destruction of [hepatitis B virus]-infected hepatocytes appears…unlikely.”
Hepatitis C infection predominated in injecting drug users, and in this group there was no evidence of an increased risk of liver cancer with lower CD4 cell counts. This is at odds with other evidence that HIV increases liver disease and liver-related death in co-infected individuals, and the investigators offer that the injecting drug users control group was more immunodeficient than their gay men counterparts and this may have masked any effect of hepatitis C on cancer risk.
While preliminary, the study provides some interesting findings on the role of hepatitis C and hepatitis C in liver cancer among people with HIV. And the results might be far reaching, the investigators end: “The present findings are also relevant for the millions of [people with HIV] worldwide who live in [hepatitis B virus] endemic areas in sub-Saharan Africa and Asia as their survival also improves on [antiretroviral therapy]”.
Reference:
Clifford GM et al. Influence of HIV-related immunodeficiency on the risk of hepatocellular carcinoma. AIDS 22:2135 – 2141, 2008.
Superinfection seen frequently in heterosexual couples in Zambia
Superinfection among heterosexual couples in sub-Saharan Africa may be surprisingly frequent, according to findings from Zambia presented on Tuesday at the 48 th Interscience Conference on Antimicrobial Agents and Chemotherapy in Washington DC.
Researchers from the Zambia Emory HIV Research Project presented evidence that 3 out of 34 people among heterosexual Zambian couples were superinfected during the time of the study. This represents a considerably more common prevalence of superinfection than has been shown in other studies.
Superinfection, or reinfection, occurs when an individual who is already HIV-positive becomes infected with a new, distinct strain of HIV in addition to their existing infection. This results in increased viral diversity within the same individual, which can be more difficult for the immune system to control, causing increases in viral load and possibly faster disease progression.
This study looked at cohabiting heterosexual couples in Zambia who were originally infected with genetically distinct strains of clade C HIV. These couples were drawn from the larger Zambia Emory HIV Research Project (ZEHRP), a cohort of HIV-discordant couples. Although HIV prevention efforts reduced HIV transmission amongst couples in the ZEHRP cohort, the uninfected partners still become HIV-positive at an annual incidence rate of 8%. Roughly 15% of these new infections come from someone other than the participant's cohabitating partner.
This superinfection sub-study looked at 17 couples in which both partners were HIV-infected, but with genotypically distinct viruses. Three of the 34 individuals in the study (nearly 9%) were confirmed as being superinfected. In one case, the male partner, who was already chronically infected, became superinfected from an outside partner. He was the source of his wife's initial infection; she then became superinfected from another outside partner. In a third case, a male partner became superinfected from his chronically infected spouse.
The cases of superinfection were identified by a two-phase genotypic analysis. First, a new assay ( heteroduplex mobility assay, or HMA) screened for variations in the HIV gp41 protein. This was followed up by phylogenetic analysis of the HIV env gene. These analyses confirmed the emergence of distinct, genetically unrelated infections in each of the three people at time points after their original infection. The analyses also showed that the superinfections resulted in new, recombinant strains of HIV in all of the superinfected people. In two cases, superinfection was accompanied by a ten-fold increase in viral load.
The investigators concluded that, in this retrospective study of a small, specific population, " superinfection appears to be a frequent event," seen in 3 out of 34 individuals studied.
These findings were drawn from a particular group of heterosexual Zambian couples. There is no reason to assume that they would carry over to other populations, since so many factors might vary. (E.g., the HIV subtype C seen in all couples in this cohort is only one of many viral subtypes, which tend to be highly localised.) However, these results indicate that, in at least some populations, superinfection might be much more common than supposed.
Reference
Kraft CS et al. HIV-1 superinfection in cohabiting Zambian heterosexual couples. 48 th Interscience Conference on Antimicrobial Agents and Chemotherapy, poster abstract H-4049, Washington DC, 2008.
Disclaimer: Please don’t assume that GMFA or the London Gay Men’s HIV Prevention Partnership endorse or oppose the points of view of the authors. Please read these articles critically. Sometimes articles may contain mis-statements, we believe they are important to include because of the information they contain or the arguments they put forward. If you have a story or article on STI or HIV prevention which you would like to be distributed please forward it to lgmhpp.update@gmfa.org.uk.
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