Category: HIV

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.

Sexual behaviour in UK

The National Survey of Sexual Attitudes and lifestyles (Natsal) has been investigating sexual behaviour across a wide range of people, geographical spread and life styles at 10 year intervals since 1990. Natsal is the most extensive, authoritative and accurate investigation of sexual behaviour in the United Kingdom.

The latest report was published as always in the Lancet. The survey shows some interesting changes in sexual behaviour including a narrowing in the gap between men and women in same sex relationships.

Over 15,000 pople were interviewed using validated methodology that minimises bias.  Data were compared between Natsal-1 (1990—91), Natsal-2 (1999—2001), and Natsal-3.

82·1% of men and 77·7%  of women reported at least one sexual partner of the opposite sex in the past year. The proportion generally decreased with age, as did the range of sexual practices with partners of the opposite sex, especially in women.

The increased sexual activity and diversity reported in Natsal-2 in individuals aged 16—44 years when compared with Natsal-1 has generally been sustained in Natsal-3, but in men has generally not risen further. However, there was evidence of increased sexual activity and also increase in same sex activity in women.

In women the number of male sexual partners over the lifetime , proportion reporting ever having had a sexual experience with genital contact with another woman , and proportion reporting at least one female sexual partner in the past 5 years  increased since the last report in 2000.

Interestingly the reported number of occasions of heterosexual intercourse in the past month had reduced but there was a reported expansion of heterosexual sexual repertoires—particularly in oral and anal sex—over time.

Also of note: while acceptance of same-sex partnerships increased so did  intolerance of non-exclusivity in marriage  in men and women in the latest survey.

The authors concluded that:

“Sexual lifestyles in Britain have changed substantially in the past 60 years, with changes in behaviour seeming greater in women than men. The continuation of sexual activity into later life—albeit reduced in range and frequency—emphasises that attention to sexual health and wellbeing is needed throughout the life course.”

Bacterial vaginosis (BV): a common cause of vaginal discharge in need of more research

Bacterial vaginosis (BV) is a common condition in women presenting as a malodorous vaginal discharge. The  smell is often worse after sex and arround the menstrual period. Occasionally there is an associated  itching or burning sensation although most women with BV only have the discharge. BV can also be detected in women who are totally symptom free.

BV is caused by an imbalance of the normal vagina flora and its mechanism remain poorly understood. An updated review by the Centre for Disease Control (CDC), USA confirms a commonly observation that BV follows sexual intercourse with a new partner and multiple partners as well as vaginal douching.

BV, itself an benign though troublesome nuisance is associated with increased risk of a number of infections or conditions:

  • Having BV can increase a woman’s susceptibility to HIV infection if she is exposed to the HIV virus.

  • Having BV increases the chances that an HIV-infected woman can pass HIV to her sex partner.

  • Having BV has been associated with an increase in the development of an infection following surgical procedures such as a hysterectomy or an abortion.

  • Having BV while pregnant may put a woman at increased risk for some complications of pregnancy, such as preterm delivery.

  • BV can increase a woman’s susceptibility to other STDs, such as herpes simplex virus (HSV),chlamydia, and gonorrhea.

  • The bacteria that cause BV can sometimes infect the uterus (womb) and fallopian tubes (tubes that carry eggs from the ovaries to the uterus). This type of infection is called pelvic inflammatory disease (PID).
  • Pregnant women with BV more often have babies who are born premature or with low birth weight (low birth weight is less than 5.5 pounds). Pregnant women who have had previous premature of low birth weight babies should be tested and treated for BV in third trimester regardless of symptoms.

Human papillomavirus may increase acquisition of HIV

Many sexually transmitted infections (STI) such as herpes and other ulcerative STI’s, chlamydia and gonorrhoea have been known to be associated with increased acquisition of HIV.

A recent meta-analysis in the journal Sexually Transmitted Infections suggests that human papillomavirus (HPV) infections, which is associated with genital warts as well as a number of malignancies, may also be associated with sexual transmission of HIV.

Since HPV is the commonest sexually acquired STI, this association, if confirmed, will have important public health consequences. This is particularly true as most sexually acquired HPV infections can be prevented by  vaccinating children.

 

HPV and HIV acquisition
HPV and HIV acquisition

 

 

What is in the May issue of STI

The latest issue of STI (Sexually Transmitted Infections) contains articles on increasing resistance of bacterial STI’s, a successful  educational interventions in South London to encourage HIV testing and data supporting the willingness by a substantial section of men who have sex with men to use pre-exposure prophylaxis for HIV.

particularly worrying is the emergence of a novel strategy by the gonococcus to avoid detection by the now widely used DNA amplification methods.

Non-disclosure of known HIV status in patients visiting a sexually health clinic

Currently in the UK it is estimated that 24%, approximately 22 200 individuals, are unaware of their HIV infection . These data are derived from statistical modelling of many  surveillance, and survey-based data sources. One of the surveillance programmes used is the unlinked anonymous HIV seroprevalence survey, the GUMAnon Survey, where patients who have blood taken at a sexually health clinic would in addition give an additional sample which is tested for HIV after the sample is completely anonymised. The limited information accompanying the sample includes whether the person is known to be HIV positive, has a test in the clinic or refuses an HIV test.

A recent study published in the journal Sexually Transmitted Infections (STI) attempted to identify HIV-infected individuals who attend a genitourinary clinics in the UK aware of their HIV status but fail to tell the clinic they are infected, or on treatment.  In this study in addition to anonymised HIV testing the positive samples had viral load (VL) estimation and after excluding known HIV positives the remaining the samples were analysed for the presence of a panel of antiretroviral drugs.

The authors identified 130 individuals attending a single London sexually transmitted infection clinic in 2009 who refused an HIV test.  Of 28 patients identified by the anonymised test  as being HIV positive who had not admitted to being infected 10 patients underwent a test at the clinic and received a positive test.

The other 18 had  refused an HIV test, although found to be positive by the anonymised test. Thirteen of these (72%, 95% CI: 47% to 90%) had a blood viral load (VL) below detection level  (n=11) or VL <1000 copies/ml (n=2) suggesting they were on antiretroviral treatment. Eight had sufficient blood to undergo antiretroviral testing, and all were positive for the presence of drug; all with therapeutic levels of clinically appropriate combinations.

Thus nearly three quarters of HIV positive patients (72%) who refused an HIV test, and hence would have been considered as not knowing their HIV status, were indeed aware of their status and are on treatment.

These results “presents a number of challenges and dilemmas both for clinics and surveillance systems” says Jackie Cassell, editor of STI journal, who went on to also points out the difficult issues of confidentiality in sexual health services in the age of electronic health records.

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.

Lancet issue on the state of global health

The Lancet has devoted an entire issue to various aspects of global health. The issue is available free for download.

An edited extract from the executive summary follows:

The Global Burden of Disease Study 2010 (GBD 2010) is the largest ever systematic effort to describe the global distribution and causes of a wide array of major diseases, injuries, and health risk factors.

The results show that infectious diseases, maternal and child illness, and malnutrition now cause fewer deaths and less illness than they did twenty years ago. As a result, fewer children are dying every year, but more young and middle-aged adults are dying and suffering from disease and injury.

Thus non-communicable diseases, such as cancer and heart disease, become the dominant causes of death and disability worldwide.

Since 1970, men and women worldwide have gained slightly more than ten years of life expectancy overall, but they spend more years living with injury and illness.

 

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