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.

One in ten men in Britain report paying for sex sometime in their life – a national study

The National Survey of Sexual Attitudes and Lifestyles (NATSAL) is a survey of men and women carried out in the Britain every 10 years. It remains the most extensive and accurate study of sexual behaviour in a carefully selected population of men and women in the UK that reflect the population of sexually active individuals.

Natsal-3 is a  sample survey of 15,162 men and women (6,293 men) aged 16–74 years, resident in Britain, undertaken between September 2010 and August 2012. Participants were interviewed using a combination of face-to-face, computer-assisted, personal interviewing (CAPI) and computer-assisted self-interviewing (CASI). The more sensitive questions, including those on paying for sex and sex while outside the UK, were asked in the CASI.  

Kyle Jones and her colleagues reported on the results of the questions relating to men who admitted to have paid for sex. 

Their results show that round one in 10 men in Britain report having ever paid for sex at some time. These men are more sexually active than men who do not report having had paid for sex. They have a higher number of sexual partners, only a minority (18.4%) of which are paid.

They are also more likely to report a diagnoses of a sexually transmitted infection (STI) even when accounting for their disproportionately larger number of sexual partners (which is considered the most important behavioural variable associated with STI diagnoses).

This evidence strongly supports the idea that this subgroup of men are a bridge for the sort of sexual mixing (dissociative mixing) that increases the spread of STIs.

Men who pay for sex (MPS) are most likely to be aged between 25 and 34 years, single, in managerial or professional occupations, and have high partner numbers.

After adjusting for the key risk behaviour of sexual partner numbers, these men still report many other sexual behaviours, such as having new foreign partners while outside the UK, less attendance at STI clinic and less condom use. They therefore show an increased vulnerability to STI without taking the necessary precautions.

Interestingly, for some reported behaviours, such as sex partners outside the UK, same sex contact, sex partners found online, and concurrent partners (more than one partner at any time), total and paid partner numbers increase.

This suggests that MPS exhibiting these behaviours have higher lifetime partner numbers than other MPS as well as higher paid partner numbers, putting them at a higher risk for STIs than other MPS.

sexual health teaching at schools works for girls better than boys

Men and women, aged 17–24 years, were interviewed from 2010–2012 for third National Survey of Sexual Attitudes and Lifestyles in the UK. The authors  examined how the source of information about sexual matters was associations with sexual behaviours and outcomes.

The study looked at the main source of information (school, a parent or other); age and circumstances of first heterosexual intercourse; unsafe sex and distress about sex in past year; experience of sexually transmitted infection (STI) diagnoses. Women were also asked if they ever had non-volitional sex or an abortion.

The results,  published in the BMJ, concluded that gaining information mainly from school was associated with reduction of a range of negative sexual health outcomes, particularly among women. These included, older age at first sex, less likelihood of unsafe sex and previous STI diagnosis. In all cases the effect was more significant for women.

Women were also more likely to be sexually competent at first sex and less likely to have  non-volitional sex, abortion and distress about sex. 

Gaining information mainly from a parent was associated with some of these, but fewer participants cited parents as a primary source.

The findings emphasise the benefit of school and parents providing information about sexual matters and argue for a stronger focus on the needs of men.

Effectiveness of alcohol advise in sexual health clinics

Are sexual health (sexually transmitted infection) clinics a suitable venue to give advise on alcohol abuse? A recently published randomised controlled trial of rapid screening and advise in three London-based sexual health clinics showed little effect of screening and advise on alcohol consumption, or unsafe sexual behaviour six months later.

802 people aged 19 years or over who attended one of three sexual health clinics and were drinking excessively were randomised to either brief advice or control treatment. Brief advice consisted of feedback on alcohol and health, written information and an offer of an appointment with an Alcohol Health Worker. Control participants received a leaflet on health and lifestyle.

The primary outcome was mean weekly alcohol consumption during the previous 90 days measured 6 months after randomisation. The main secondary outcome was unprotected sex during this period.

Among the 402 randomised to brief advice, the adjusted mean difference in alcohol consumption at 6 months was −2.33 units per week (95% CI −4.69 to 0.03, p=0.053) among those in the active compared to the control arm of the trial.

Unprotected sex was reported by 53% of those who received brief advice, and 59% controls (p=0.496).

In a linked leading article in the journal Sexually Transmitted Infections Keith Radcliffe and Nicola Thornley review the links between alcohol misuse and unsafe sexual practices. They report conflicting information as to the benefits of behaviour intervensions, both in terms of reduction in the consumption of alcohol and in unsafe sexual behaviour.

The current study adds to the growing literature on the difficulties of behaviour intervention in having lasting effects on behaviour changes, whether it is sexual or eating habits.

Clearly more work is needed to help translate knowledge into behaviour.

 

Malcom Gibb

Malcom Gibb who had served on the Board of Trustees since 2009 sadly passed away in early January this year. Malcom not only supported STIRF since its early inception but through his links with the Jo Li Foundation provided regular financial support. Without his help STIRF would not have been able to fund many of the projects that were successfully completed. The board of Trustees of STIRF send their deepest condolences to the family and friends of Malcom. I will miss him, not only as a valued colleague, but even more as a very dear friend.

Call for HPV vaccination for school age boys

In a recent editorial in the British Medical Journal (available only on subscription), Margaret Stanley and coauthors urged the UK government to introduce a gender neutral vaccination programme against HPV in schools for boys and girls aged 12-13 to reduce not only ano-genital warts but HPV-related cancers. These include cervical cancer in women, anal cancers in men who have sex with men and oropharyngeal cancers.

The authors point out that  oropharyngeal cancers have the fastest rising incidence (15% per year) and anal cancer rates in the UK have risen by nearly 300% in the last 40 years..

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.