Category: HIV

Start HIV treatment regardless of CD4 count

A large international study (INSIGHT START) published in the New England Journal of Medicine has found that starting antiretroviral therapy immediately after human immunodeficiency virus (HIV) diagnosis rather than waiting until a patient’s CD4+ count has declined is of considerable benefit.

The results of the study were also released at the International AIDS Society conference in Vancouver, Canada, on 20 July.

Currently most authorities strongly recommend starting anti-HIV once CD4+ count drops to below 350 cells per cubic millimetre. Until the INSIGHT START study there was no randomized trials  showing the benefits and risks of initiating antiretroviral therapy in patients with asymptomatic HIV infection who have a CD4+ count of more than 350 .

START study conducted in 35 countries randomly assigned 4,685 HIV positive patients to either receive immediate antiretroviral therapy (median CD4+ of 650) or wait until their counts fell to below 350.

After a mean follow up of 3 years the study found that 42 patients in the immediate-initiation group died, as compared with 96 patients in the deferred-initiation group  (95% confidence interval, 0.30 to 0.62; P<0.001). Reduction in deaths were largely from tuberculosis, Kaposi’s sarcoma, and malignant lymphomas – conditions that can occur in HIV-infected individuals with only moderately damaged immune systems.

Currently the WHO requires all patients with HIV to be treated CD4+ of 500 or less. WHO may need to extend that to treating anyone at diagnosis. This would not only benefit the individual but by reducing viral shedding in body secretions reduce transmission and hence have a public health benefit. Moreover some of the costs of starting early would be offset by not needing to perform repeated CD4+ counts.

Transmitting an STI and the law

On May 8 2014 the UK Court of Appeal dismissed the appeal of David Golding against a 14 month prison sentence for transmitting herpes to his partner.

An Editorial in the BMJ by Emily Clarke an colleagues highlights the numerous and  complicated issues that arise from this verdict including:

what constitutes grievous bodily harm,

how you determine that sexual transmission has occurred,

how serious is herpes infection, and

what this judgement means both for health care workers who advise and inform patients on the risks of transmission and on the infected individual and their duty of informing all partners of potential risk of transmitting an infection even during asymptomatic shedding.

The Editorial correctly highlights the dangers of criminalizing sexually transmitted infections and the various problems that arise from this judgement which was based on a law passed 170 years ago addressing totally unrelated issues and at a time when STI’s were not understood as they are today.

Human rights violations against sex workers: burden and effect on HIV

This is part of a series of articles on HIV and sex workers published by The Lancet and freely available.

In this article Michelle Decker et al  reviewed evidence from more than 800 studies and reported on the burden and HIV implications of human rights violations against sex workers.

Abuses of human rights are  perpetrated by both state and non-state actors. Such violations directly and indirectly increase HIV susceptibility, and undermine effective HIV-prevention and intervention efforts.

Violations include homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing.

Abuses occur across all policy regimes, although most profoundly where sex work is criminalised through punitive law.

The authors conclude that protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and wellbeing.

Research findings affirm the value of rights-based HIV responses for sex workers, and underscore the obligation of states to uphold the rights of this marginalised population.

Bacteria living in men’s penises could be promoting sexually transmitted infections

The debate about whether to circumcise or not continues to raise passions. The fact that male circumcision reduces acquisition of HIV from an infected partner has been proven by three randomised clinical trials. And male circumcision may also protect against other sexually transmitted infections.

One of the most powerful arguments against male circumcision is that it only addresses acquired infections in the male. A recent report in the Scientist that bacteria living under the foreskin can promote STI’s would help answer this critique.

Just as the vaginal microbiome differs among women and changes over time, the penis is home to a variety of bacteria that vary with age, sexual activities, and whether the man is circumcised, among other things. And it’s not just the skin that envelops the male sexual organ that’s inhabited by microbes: researchers continue to identify bacteria that dwell within the urogenital tract, a site once considered sterile in the absence of infection.

David Nelson and colleagues at Indiana University in Bloomington found evidence to suggest that the sexually transmitted pathogens in the urogenital tract were obtaining metabolites from other microbes. “There was a signature in the chlamydial genome that suggested this organism might be interacting with other microorganisms,” said Nelson. “That’s what initially piqued our interest. And when we went in and started to look, we found that there were a lot more [microbes] than we would have anticipated being there.”

The researchers found that some men pass urine containing a variety of lactobacilli and streptococci species, whereas others have more anaerobes, like Prevotella and Fusobacterium. In terms of overall composition, “we see a lot of parallels to the gut,” said Nelson, noting that there doesn’t seem to be a standout formula for a “healthy” urogenital tract. Commensal microbes within the urethra could make a man more susceptible to infection by supporting colonization by pathogens like Chlamydia, whereas bacteria that consume the environment’s nutrients could help prevent it. “We just don’t know at this point,” said Nelson.

To date, circumcision is the known largest influence on the composition of the penis microbiome. In a 2010 PLOS ONE paper, Lance Price of the Translational Genomics Research Institute in Phoenix, Arizona, and his colleagues showed that the bacteria that colonized the base of the penis’s tip, or glans, varied before and after circumcision. More specifically, the researchers found fewer anaerobic bacteria within six months after the men in a study were circumcised. Those findings have since been confirmed.

Definitely further studies in this field should be encouraged.

Sexual health of female sex worker in the UK

Female sex workers (FSWs) are assumed to be at increased risk of sexually transmitted infections (STIs). Using routine STI surveillance data, McGrath-Lone et al  in an article published in the latest issue of Sexually Transmitted Infections investigated differences in sexual health between FSWs and other female attendees at sexual health (genitourinary medicine – GUM) clinics in England.

They reported on 2704 FSWs visiting to 131/208 GUM clinics, (primarily large, FSW-specialist centres in London) in 2011. By comparison with other female attendees, FSWs travelled further for their care and had increased risk of certain STIs (eg, gonorrhoea Odds Ratio: 2.76, p<0.001). Significantly migrant FSWs had better sexual health outcomes than UK-born FSWs (eg, period prevalence of chlamydia among those tested: 8.5% vs 13.5%, p<0.001) but were more likely to experience non-STI outcomes (eg, pelvic inflammatory disease OR: 2.92, p<0.001).

They concluded that although FSWs in England have access to high-quality care through the GUM clinic network, there was evidence of geographical inequality in access to these services.

A minority do not appear to access STI/HIV testing through clinics, and some STIs are more prevalent among FSWs than other female attendees.

Targeted interventions aimed at improving uptake of testing in FSWs should be developed, and need to be culturally sensitive to the needs of this predominantly migrant population.

Bacterial vaginosis fact sheet update by CDC

Bacterial vaginosis (BV) is the commonest vaginal infection seen in women. The Centre of Disease Control (CDC) has recently updated its fact sheet on this common condition.

In summary 

BV is linked to an imbalance of “good” and “harmful” bacteria that are normally found in a woman’s vagina. Having a new sex partner or multiple sex partners and douching can upset the balance of bacteria in the vagina and put women at increased risk for getting BV.

BV can cause some serious health risks, including:

Increasing your chance of getting HIV if you have sex with someone who is infected with HIV;

If you are HIV positive, increasing your chance of passing HIV to your sex partner;

Making it more likely that you will deliver your baby too early if you have BV while pregnant;

Increasing your chance of getting other STDs, such as chlamydia and gonorrhoea.

These bacteria can sometimes cause pelvic inflammatory disease (PID), which can make it difficult or impossible for you to have children.

Important new research on lymphogranuloma venereum (LGV) in gay men in the UK

Lymphogranuloma venereum (LGV), previously predominantly a tropical disease, re-emerged in Western Europe in 2003, and has arguably now regained endemic status in many countries. It remains largely contained within in a population of men who have sex with men (MSM) with high rates of other sexually transmitted infections (STIs) including HIV, though a first female case was reported in Sexually Transmitted Infections in 2012.

A recent series of papers in Sexually Transmitted Infections sheds further light on the risk factors for rectal LGV in men who have sex with men in the UK, the key symptoms and ways in which LGV presents to the clinician, and pitfalls in the currently recommended treatment and prevention strategies.

Moreover, microbiological  characteristic of LGV repeaters using surveillance data has convinced Rönn and colleagues that behaviour alone does not explain reinfection, which they see as related to centrality in sexual networks.

Together these four articles add important information on the clinical presentation, epidemiology and treatment of LGV in MSM.

Project on the role of shame in failure to attend for STI and HIV testing shame approved for funding

The 2013 round of applications for funding has resulted in approval for the following pilot project:

Designing a Research project for understanding the role of stigma and shame in STI and HIV testing 

The project will be headed by Phil Hutchinson, Ph.D. (Man.), M.A. (Man.), B.A. (London), Senior Lecturer in Philosophy, Manchester Metropolitan University.

The aim of the preliminary project is to find the methodology to test the hypothesis: is shame one of the reasons for failing  to attend for STI and HIV testing. The project will be completed within six months involving setting up workshops with groups involved with both patient groups and those sexual health care.

HIV testing in the street: a useful tool for widening coverage

The March issue of the journal STI included an article by Sonia Fernandez-Balbuena and colleagues in Madrid which demonstrated that offering HIV testing on the street  may allow a significant number of hard-to reach populations to offer themselves for HIV testing.

Of 7552 persons in various Spanish cities who were asked to full a brief questionnaire and offered HIV testing 3517 participants (47%) were first-time testers. These included 24% of men who have sex with men , 56% of exclusively heterosexual men and 60% of women. 22 undiagnosed HIV infections were detected with a global prevalence of 0.6% and 3.1% in MSM.

The authors concluded that their community programme attracted a substantial number of persons previously untested and particularly hard to reach, such as those with low education and MSM who were least involved in the gay community.

In their view a decisive in decisive factor for almost two of every three persons who had never been tested. was the visibility of the programme.