A greater understanding of the impact of HIV treatment on prevention is changing the experience of being in a relationship with a partner of a different HIV status, according to a qualitative Australian study published last week in the Sociology of Health and Illness. A biomedical intervention appears to be having unexpected effects – loosening the association of serodiscordant relationships with ‘risk’ and helping couples to experience their relationships as normal and safe.
Asha Persson of the University of New South Wales reports that people’s views about treatment as prevention have changed significantly in recent years. She previously researched the topic in 2009, soon after the ‘Swiss Statement’ was issued. At that time, people in a relationship with a partner of a different HIV status often expressed scepticism or uncertainty about the idea that HIV treatment could make a person non-infectious. They did not always see the relevance of the information to their own lives.
But in her more recent interviews, conducted in 2013 and 2014, couples readily discussed the implications of having an undetectable viral load. HIV treatment appears to be transforming the social and sexual lives of people living with HIV and their partners.
The research specifically focuses on so-called ‘serodiscordant couples’, in other words those in which one person has HIV and the other does not. The public health literature on serodiscordant relationships typically focuses on the risk of HIV transmission and tends to see such a relationship as inherently problematic. In contrast, Persson found that her interviewees wanted to stress how normal and positive their relationships were, with HIV being seen as ‘no big deal’.
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Test-and-treat’ is unlikely to be an effective strategy to control the HIV epidemic in the United States without improvements in retention in care, investigators argue in the online edition of Clinical Infectious Diseases. A mathematical model suggested that without interventions to address poor levels of engagement in HIV care, there could be as many as 1.39 million new HIV infections in the US over the next 20 years, at a cost of $256 billion. Targeting testing and linkage would only prevent 21% of these new infections. But a package of interventions comprising testing, linkage and retention in care would prevent over half of the projected new infections, reduce AIDS-related mortality by almost two-thirds and be cost effective.
“To alter the course of the HIV epidemic in the United States, strategies of ‘test and treat’ alone may be insufficient; attention to the full continuum of care will be essential,” comment the authors.
United States guidelines recommend expanded HIV testing and antiretroviral therapy at any CD4 count as strategies to reduce rates of AIDS-related deaths and HIV transmissions. However, this approach may not be as effective as hoped. Recent research has shown that there is significant attrition at each stage of the HIV care continuum in the US. Up to a fifth of HIV-infected individuals are undiagnosed; 20% of recently diagnosed patients are not linked to care within 90 days; 54% of patients are not retained in care; only 30% of diagnosed patients have an undetectable viral load.
Diagnoses of gonorrhea among men who have sex with men are apparently rising in the United States. Centers for Disease Control and Prevention (CDC) researchers, in order to determine demographic information, interviewed a random sample of individuals diagnosed with the sexually transmitted infection (STI) in 12 areas across the country between 2010 and 2013. The researchers then used census and Gallup opinion polling data to estimate the respective sizes of the U.S. MSM, heterosexual male, and female populations by age group at the state, county and city levels.
In 2010, there were an estimated 1,169.7 diagnoses of gonorrhea per 100,000 MSM. In other words, about 1.17 percent of MSM contracted the STI that year. This rate rose 26 percent in three years, hitting 1,474.4 diagnoses per 100,000 MSM, or 1.47 percent, in 2013. Looking at MSM according to age bracket, those between 25 and 29 years of age had the highest diagnosis rate: 3,400 per 100,000, or 3.4 percent.
During the study period, gonorrhea diagnosis rate among MSM was between 10.7 and 13.9 times higher than that of women or heterosexual men. While the researchers speculate that the rising gonorrhea rates may be indicative of a national trend, they caution that the data in this study is not nationally representative.
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The uptake of PrEP in people who need it risks being limited due to low levels of awareness, gaps in health insurance, opaque bureaucratic procedures, under-usage of medical services, and limited awareness and skills in healthcare providers, according to an analysis published online ahead of print in Clinical Infectious Diseases. Also taking into account sub-optimal adherence among some PrEP users, the researchers conclude that just 15% of gay men in the American city of Atlanta who could benefit are likely to achieve protection from HIV with PrEP.
The PrEP care cascade
Colleen Kelley and colleagues at Emory University outline a ‘care cascade’ or ‘continuum of care’ for PrEP which identifies the key steps in the process of getting hold of PrEP and using it effectively. Analysis of the care cascade can help focus attention on where there are significant barriers to a person moving on to the next step.
After two and a half years of trials, a new study has found no new HIV infections among a group of people on pre-exposure prophylaxis (PrEP). For 32 months, researchers at the Kaiser Permanente Medical Center in San Francisco tracked the health of over 600 people as they used Truvada daily to prevent the virus in a real-world setting.
The average age of the study participants was 37, and 99 percent were men who have sex with men. The average length of individual usage was 7.2 months. Members of this group also reported a higher likelihood of having multiple sex partners than those not using PrEP. No one in the study contracted HIV.
Lead author Jonathan Volk, a physician at Kaiser Permanente San Francisco, emphasized that this is the first time such a study has been done in a clinical practice setting at this size. The findings were published Wednesday in Clinical Infectious Diseases, a leading journal of studies on infection disease.
The medical staff at the Pitt Men’s Study emphasize that PrEP is not a substitute for condoms. It should be used in addition to condoms, to further reduce your risk. It is also important to note that PrEP doesn’t protect against other STDs like syphilis, chlamydia, and gonorrhea. To learn more about PrEP, check out the CDC’s Website. If you have questions about PrEP, you can speak to your doctor. You can also call the PrEP clinic at the University of Pittsburgh Medical Center: (412) 647-0996.
The greatest barriers to these teenage males getting tested are not knowing where to go to get an HIV test, worries about being recognized at a testing site and—to a lesser degree—thinking they are invincible and won’t get infected.
“Understanding the barriers to testing provides critical information for intervening, so we can help young men get tested,” said study first author Gregory Phillips II, a research assistant professor of medical social sciences at Northwestern University Feinberg School of Medicine and an investigator for the IMPACT LGBT Health and Development Program at Feinberg.
“Rates of new HIV infections continue to increase among young gay and bisexual men,” said Brian Mustanski, principal investigator of the study, an associate professor of medical social sciences at Feinberg and director of IMPACT. “Testing is critical because it can help those who are positive receive lifesaving medical care. Effective treatment can also help prevent them from transmitting the virus to others.”
The study will be published Aug. 26 in the Journal of Adolescent Health. Continue reading.
Daily post-exposure prophylaxis (PEP) with single tablet emtricitabine/tenofovir/rilpivirine (Complera, Eviplera) has excellent completion rates and good side-effect and safety profiles, Australian investigators report in the online edition of Clinical Infectious Diseases.
The open-label, non-randomised study involved 100 men who have sex with men (MSM) requiring PEP after possible sexual exposure to HIV. Treatment lasted 28 days and was completed by 92% of participants. Side-effects were mild, the most common being nausea and tiredness. There were no serious adverse events.
Prompt PEP, after possible sexual or occupational exposure to HIV, can reduce the risk of infection. Guidelines recommend triple-drug therapy, ideally commenced within 72 hours of exposure. Failure of PEP has been linked to poor treatment adherence or the premature discontinuation of treatment. A recent analysis of 97 PEP studies found that only 57% of patients completed their four-week course of treatment.
The combination pill emtricitabine/tenofovir/rilpivirine provides well tolerated and easy-to-take once-daily HIV therapy. Though it must be taken with food, investigators from Australia hypothesised that the combination pill would provide convenient and safe PEP.