Category: HIV services

HIV treatment of infected partner reduces transmission in heterosexual couples

Based on results of randomised clinical trials the World Health Organization recommends antiretroviral drugs for all HIV infected adults in serodiscordant heterosexual relationships at all stages of the disease. But does this strategy work in real life situations?

A recent study published in the Lancet has for the first time reported that such a public health approach is feasible and the outcomes are sustainable at a large scale and in a developing country setting.

New analyses from China look encouraging, say researchers. Between 2003 and 2011, uninfected partners of treated people were significantly less likely to seroconvert than uninfected partners of untreated people (1.3 infections/100 person years (95% CI 1.2 to 1.3) v 2.6 (2.4 to 2.8)). After adjustments, treatment of infected partners was associated with a 26% reduction in risk of transmission to uninfected partners (hazard ratio 0.74, 0.65 to 0.84).

The analyses compared around 24 000 treated couples with nearly 15 000 untreated couples registered in China’s national HIV epidemiology database.

It is hard to say whether treatment was entirely responsible for reducing transmission, because people who were treated were older, sicker, and may have had less sex, or less risky sex, than those who were not yet treated, says a linked comment by the Lancet

But the findings hint at a direct effect. Treated couples looked better protected, despite the relatively low CD4 counts (and presumably higher viral loads) necessary for treatment in China.

Treatment was associated with lower transmission when HIV had been acquired from a transfusion of blood products (50% of the treated couples) or heterosexual sex, but not when it had been acquired from injecting drugs.

New HIV infection in UK in men who have sex with men exceeds heterosexual transmission after many years

Annual report of HIV infections in the United Kingdom in 2001 published by Health Protection Agency (HPA) show that for the first time in  many years newly diagnosed infections were higher in men who have sex with men (MSM) than transmission through heterosexual intercourse.

By the end of 2011, there were an estimated 96,000 (95% credible interval 90,800 – 102,500) people were living with HIV in the UK. Approximately one quarter (22,600, 24% [19%- 28%]) of these were undiagnosed and unaware of their infection. Fig 1

Fig 1. People infected with HIV at the end of 2011

 

This is an increase from the 91,500 people estimated to have been living with HIV by the end of 2010. The estimated prevalence of HIV in 2011 was 1.5 per 1,000 (1.5-1.6) population of all ages, 2.1 per 1,000 (1.9 – 2.3) men and 1.0 per 1,000 (1.0 – 1.1) women.

The rise in new diagnosis in MSM (Fig 2) is particularly worrying as nearly half the patients (47%) are diagnosed late when their immune system is already compromised increasing the chance of a fatal outcome within one year of diagnosis ten fold. These deaths are totally avoidable with the use of anti-viral therapy early in the infection.

 

Fig 2. New cases of HIV by exposure category

 

STIRF: new projects approved

In this year’s funding round we received six applications. After sending them for external peer review by experts, the Scientific Committee approved two projects for funding in 2013 which was submitted to the Trustees.

Project 1: Chlamydia trachomatisis the most common sexually transmitted infection effecting young people in the UK. It infects one in ten of all women aged 15-25 and can cause serious long term complications such as pelvic inflammatory disease and infertility. According to the Health Protection Agency in 2011 in England and Wales 147,594 infections were diagnosed in 15 to 24 year olds.

Recent evidence for emergence of resistance to the commonly used antibotics used in eradicating chlamydia is very worrying. We are delighted to fund Emma Hathorn as part of a multi-centre study to evaluate the incidence of  chlamydia resistance in people attending a clinic for sexually transmitted infections.

Antimicrobial resistance in Chlamydia trachomatis: is it a reality? STIRF-022

 

Project 2: There is increasing focus on involving patients and what they perceive are their actual needs when delivering clinical services in the NHS. This is particularly important in the fast developing field of HIV where new management strategies and new treatments take place within the background of shrinking funding. These clearly call for new ways of delivering these services more efficiently as well as more effectively. It is with this in mind that STIRF decided to fund the nurse-led project by Lucy Land that is taking steps to objectively define these priorities as seen from the HIV-infected patients perspective.

Development of a weighting scale to evaluate the relative importance of items in a validated HIV patient satisfaction questionnaire. STIRF-020

This study aims to refine a questionnaire they developed and validated with the help of HIV-infected patients to find issues that are more important and therefore need to be prioritised in development of HIV services.

Thanks to all the researchers who submitted and to the reviewers who gave their valuable time for free.

Pre-exposure prophylaxis can be a cost effective addition to other preventative options for men who have sex with men

HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by uninfected individuals to prevent HIV infection, has demonstrated effectiveness in preventing acquisition in a high-risk population of men who have sex with men (MSM).

Researchers from the Imperial College London have developed a mathematical model representing the HIV epidemic among MSM and transwomen (male-to-female transgender individuals) in Lima, Peru, to investigate how PrEP can be used cost-effectively to prevent HIV infection in such populations.

The study reported that strategic PrEP intervention could be a cost-effective addition to existing HIV prevention strategies for MSM populations.

However, PrEP will not arrest HIV transmission in isolation because of its incomplete effectiveness and dependence on adherence, and because the high cost of programmes limits the coverage levels that could potentially be attained.

15-year survival of patients on antiretroviral drugs similar to general population

In a recently published study by Hamish McManus and colleagues reported on long term survival and mortality in HIV-positive patients receiving anti-retroviral medication (cART )in the Australian HIV Observational Database (AHOD) and compared them to the general population.

They showed that observed mortality remained fairly constant by duration of cART and was modelled accurately by accepted prognostic factors.These rates did not vary much by duration of treatment.

Unlike previous studies which had shown an increase in mortality in HIV patients compared to matched non-infected populations changes in mortality with age were similar to those in the Australian general population. The increased mortality is more pronounced in females but is observed in both sexes and is unrelated to known risk factors such as smoking, hypertension, blood fat abnormalities, or obesity and is thought to relate to long term effects of anti-reroviral therapies currently in use.

HIV Infection Among Ethnic Minority and Migrant Men Who Have Sex With Men in Britain

A study by Jonathan Elford and colleagues published in in the journal Sexually Transmitted Infection has examined human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) from different ethnic and migrant groups living in Britain.

A diverse national sample of MSM living in Britain was recruited in 2007-8 through Web sites, in sexual health clinics, bars, clubs, and other venues. Men completed an online survey that included questions on HIV testing, HIV status, and sexual behaviour. A sample of just under 12,000 white British men were used as comparison

Results: Nine hundred and ninety-one ethnic minority MSM, 207 men born in Central or Eastern Europe (CEE), 136 men born in South or Central America, and 11,944 white British men were included in the analysis.

Self-reported HIV seropositivity was low for men of South Asian, Chinese, and “other Asian” ethnicity (range, 0.0%–5.8%) and for men born in Central or Eastern Europe (CEE 4.5%) but elevated for men born in South or Central America (18.7%), compared with white British men (13.1%) (P < 0.001).

Interestingly there were no significant differences between these groups in high-risk sexual behavior (P = 0.8). After adjusting for confounding factors in a multivariable model, substantial differences in the odds of HIV infection remained for South Asian and Chinese MSM as well as for migrants from CEE, but not for other groups, compared with white British men; for example, South Asian men, adjusted odds ratio 0.43, 95% confidence interval 0.23, 0.79, P = 0.007.

The authors concluded that despite marked differences in HIV between ethnic minority, key migrant, and white British MSM  there was no significant difference in high-risk sexual behaviour between the groups studied.

Their study highlights the importance of health promotion targeting MSM from all ethnic and migrant groups in Britain.

Sex workers collective show long-term health gains of self-empowerment

A parallel AIDS conference in Kolkota, India gave the rights an update on the success of the VAMP sex-workers colective – now in its 15th year reports, reports Andera Cornwall the Guardian.

They have shown an impressive ability to minimise risk of HIV and other sexually transmitted infections in sex workers.

Founded in 1997, Vamp now has more than 5,000 members. Weekly meetings bring the collective together to tackle a wide range of issues faced by members. Health work and advocacy for sex rights’ human rights are interwoven with Vamp’s everyday work in the densely populated alleyways in the red-light districts of Sangli and other towns in the region.

Vamp’s mission is to change society. Rather than treating sex workers as victims to be rescued or rehabilitated, it demonstrates the power of collective action as a force for women’s empowerment, mobilising sex workers to improve their working conditions, and claim rights and recognition. And they’re yielding results.

The report showed how self-empowerment and education can achieve high rates of safe sex in women at high risk of sexually transmitted infections and HIV. It is yet another reminder to that the most effective way to protect this vulnerable population is to help then self-organise and self-protect rather than to criminalise prostitution.

The latter, as many studies have shown, merely drives women into the hands of criminal gangs, or leads to risk-taking sexual practices and high rates of self-harm.

Development of a questionnaire to measure patients’ satisfaction with HIV Clinics

A STIRF funded project (STIRF-012) has been completed successfully. Professor Jonathan Ross, Consultant in HIV medicine at University Hospital Birmingham and Lucy Land, Reader in Nursing at Birmingham City University have developed a questionnaire that will give patients attending an HIV clinic the opportunity to feedback their experiences of care.

A systematic review of the medical literature provided background information on what factors were important to patients attending a HIV clinic. Current users of the service were then involved in verifying this information and added their views about the issues that were important to them. For example being afforded respect, dignity and autonomy, together with an expectation of expert medical care were considered essential to a good service.

A draft questionnaire was constructed to include questions around these issues as well as others that were relevant and important to patients with HIV. This draft was tested with a group of patients and refined further. The final questionnaire was piloted on 100 clinic patients and showed that the feedback from the questionnaire could provide an accurate reflection of patients’ experiences. In the future, an annual survey using this questionnaire will be conducted and the data will be used to measure the quality of care and inform improvements in HIV clinic services.

The research had been submitted for publication