24 February 2020
News from aidsmap
Following the early closure of the HVTN 702 (Uhambo) trial, due to the experimental vaccine having no efficacy, Gus Cairns talks to Linda-Gail Bekker and Glenda Gray about the history and future of HIV vaccine research.
New strategies and approaches are needed to address the sexual health needs of middle-aged heterosexuals starting new relationships, research published in Sexually Transmitted Infections suggests. The UK study involved men and women aged between 40 and 59 years with, or considering, new sexual partners after the break-up of a long-term relationship.
A US online survey has found that although gay and bisexual men who used PrEP had significantly more condomless sex with non-primary partners than men who didn’t use PrEP they were less likely to be anxious. A relationship seen in previous studies between higher rates of condomless sex and more anxiety did not seem to operate for PrEP users.
Two recent reports highlight the low rates of smoking cessation achieved using recommended brief interventions during routine appointments at HIV clinics.
“Since your partner is not an angel… it would be prudent to use PrEP”: motivations to start PrEP in Kenya and Uganda
Qualitative research with adolescents and young adults in rural Kenya and Uganda revealed multiple factors affecting the uptake of pre-exposure prophylaxis (PrEP) to prevent HIV infection. While young people felt vulnerable to acquiring HIV, the perceived severity of infection with HIV had been diminished due to the success of antiretroviral therapy (ART).
Injecting drugs in public places linked to a higher risk of HIV, hepatitis C and overdose, Scottish survey finds
People who inject drugs in public places in Scotland are much more likely to have HIV or hepatitis C and are at higher risk of overdose and skin and soft tissue infections caused by injecting, a survey of drug users has found. Scottish investigators say that their findings provide strong evidence in support of providing safer drug consumption facilities to prevent further drug-related harm.
A study investigating the interactions in HIV-positive trans women between gender-affirming feminising hormone therapy (FHT) and antiretroviral therapy (ART) has found that blood levels of the primary female hormone estradiol were reduced by an average of 36% in women once they started taking ART. It also found that taking FHT reduced the level of the ART drug tenofovir by 17%, which was statistically significant, and of efavirenz by 9%, which was not significant.
Testing for chronic hepatitis B infection was very low in people living with HIV in Cameroon, a country with a high burden of hepatitis B, and suppression of hepatitis B virus was suboptimal in people with HIV on antiretroviral therapy, Cameroonian and French researchers report in BMC Infectious Diseases.
A case note review from 56 Dean Street, the largest HIV and STI clinic in Europe, has found that former PrEP users who get HIV are more likely to have a certain type of drug resistance than people who have never taken PrEP. However, this had little if any impact on their response to HIV treatment once they were diagnosed and started antiretroviral therapy.
Babies of South African mothers taking HIV therapy have worse health in early months – unless they are vaccinated and consistently breastfed
A South African study has found that, in general, babies born to HIV-positive mothers who are on antiretroviral therapy do not have worse health outcomes than the children of HIV-negative mothers. However, it did find that the HIV-positive mothers’ babies had more hospitalisations – especially for lower respiratory tract infections and diarrhoeal disease – in the period from eight days to three months after birth.
Editors' picks from other sources
from The Guardian
Will Nutland: The health secretary says he’s serious about tackling infection. But there are basic inequalities in who accesses PrEP.
During a historic 2015 outbreak, HIV incidence rates in Austin, Indiana – population 4000 – exceeded those in sub-Saharan Africa. Why? Spiralling opioid use – and a slow uptake on needle exchanges that could have slashed Austin’s HIV incidence by 90% if implemented before the outbreak began. The CDC says 220 other US counties face a similar risk.
from Canadian HIV/AIDS Legal Network
The Canadian HIV/AIDS Legal Network, COCQ-SIDA and HALCO are jointly intervening in “R v NG,” a precedent-setting case before the Court of Appeal for Ontario. In this case, a young man living with HIV was convicted in 2017 of aggravated sexual assault for not disclosing his HIV-positive status before sexual intercourse – despite using a condom in every instance. There is no allegation that HIV was transmitted and no evidence of any incorrect condom use.
The campaign features seven different people who take turns encouraging viewers to 'Step up, PrEP up' and explaining who should and why. As one actor says , “For kings, this queen and you royals in-between." Another adds that it's “For my now,” followed by a gay couple who say it's, “For our now.”
10 February 2020
News from aidsmap
Unanswered questions about the safety of taking PrEP during pregnancy and breastfeeding should not be allowed to stand in the way of access to PrEP for women who need it at these times, a systematic review published in the Journal of the International AIDS Society concludes. The review found no evidence of harm for women who took PrEP during pregnancy. PrEP use did not lead to higher frequencies of premature birth, stillbirth, low birth weight or poorer infant outcomes, except for one early measurement of infant body size in one small study.
Globally, more women are living with HIV than men, but in the World Health Organization (WHO) European Region, twice as many men are newly diagnosed with HIV than women each year, a study recently published in Eurosurveillance shows. Dr Otilia Mårdh of the European Centre for Disease Prevention and Control and colleagues examined demographic, clinical characteristics and trends among women diagnosed with HIV in the WHO European region, and found that half of women were diagnosed late.
Elevated fracture risk for people with HIV cannot be explained by changes in bone mineral density alone
The risk of fragility fractures is increased among people living with HIV, according to research published in the January edition of the Journal of Acquired Immune Deficiency Syndromes. This increased risk couldn’t entirely be explained by reductions in bone mineral density suggesting a wider effect of HIV and its treatment on bone health.
Providing free HIV treatment and care to migrants in Botswana would avert 16,000 new HIV infections and 500 HIV-related deaths by 2030, according to a modelling study published in PLOS ONE. Currently Botswana only provides free antiretrovirals to its citizens, excluding from eligibility migrants who make up 7% of the population, many coming from countries with a very high HIV prevalence.
Alarmingly high mortality in hospitalised patients with HIV/TB co-infection in Malawi and South Africa
A study from South Africa and Malawi published online ahead of print in Clinical Infectious Diseases highlights the urgent need for better management of people with TB and HIV co-infection. It shows how suboptimal implementation of TB and HIV standards of care is causing unnecessary human suffering and untimely deaths in people living with co-infection. This study reinforces the necessity of due diligence in ensuring that every component of the evidence-based model of care for TB and HIV is taken care of.
Over a quarter of a sample of HIV-positive gay and bisexual men in a relationship with an HIV-negative partner did not have an accurate understanding of their current viral load, investigators from the United States report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Laboratory viral load results showed that a fifth of men who believed that they were undetectable currently had a detectable viral load, and that 7.5% were virally suppressed when they thought their viral load was detectable.
The most recent of a series of national gay men's surveys in Australia shows that over one in seven (14.7%) of all the non-HIV-positive respondents in the 2018 survey is taking PrEP. A smaller survey conducted in 2017, which focused on gay men's opinions of biomedical prevention alone, found that one in five (20.5%) were taking PrEP. It also found that about one in seven (15.1%) reported that they were taking PrEP and experiencing reduced anxiety and more confidence about sex.
Peer-led community intervention substantially reduces treatment failure among adolescents living with HIV in rural Zimbabwe
A peer-led, community-based intervention with multiple components resulted in a 42% reduction in virological failure or death among adolescents living with HIV in rural Zimbabwe compared to adolescents following standard public sector care at 96 weeks follow-up.
Frailty is associated with increased mortality risk for middle-aged people living with HIV, investigators from the Netherlands report in the Journal of Infectious Diseases. Frailty was also associated with an increased risk of developing serious illnesses normally associated with ageing. The researchers, led by Dr Eveline Verheij of the University of Amsterdam, also found that frail HIV-negative individuals also had an increased risk of death and serious illnesses.
“I think cancer is deadly…it puts a stop to everything… HIV, I’d take my tablets for a little while and I’d bounce back”. This quote is from a man in his thirties, living with HIV and also diagnosed with cancer. He participated in a UK study that explored experiences of cancer care, from the perspectives of both people living with HIV and healthcare professionals. The study concludes that both HIV and cancer have a powerful and a combined impact, and that for cancer, this impact is visible, while for HIV, it is generally hidden.
Editors' picks from other sources
The failure-ridden search for a vaccine that can stop the AIDS virus has delivered yet another frustrating defeat. The HIV vaccine that had moved furthest along in human testing does not work, and the $104 million trial in South Africa evaluating it has been stopped early.
from Daily Maverick
As South Africans we realise the search for a safe and effective HIV vaccine has to continue. The early halt cannot be the end; the journey has to continue.
It’s the early, panic-inducing days of a new virus. People who may have been exposed are quarantined. Americans are being asked to keep their distance from others, just in case someone has been exposed to the virus and doesn’t show signs of infection yet. There are scary reports of deaths from the virus, and uncertainty about how it spreads – and so, just to be safe, people are buying masks.
In a setback to Gilead Sciences, a federal panel rejected its bid to invalidate a pair of patents owned by the US government for using the Truvada pill to prevent HIV, a drug that has sparked controversy due to its cost and the extent to which taxpayer dollars funded crucial research.
While index testing, a PEPFAR initiative that tracks the contacts of people who test positive for HIV, has potential benefits for individuals and communities when it is done ethically, with consent and without coercion, it can also be aggressively implemented in ways that can cause harm to individuals, undermine their rights to consent, privacy, safety and confidentiality, and can erode the trust of communities with healthcare providers.
Special issue of CATIE's publication TreatmentUpdate on weight gain as a complication or side effect of antiretroviral therapy.
05 February 2020
Sex after an HIV diagnosis
Many of the interviewees said that their initial reaction to diagnosis was to stop having sex. This was largely determined by fear of transmitting the virus and fear of rejection. One woman said:
“After diagnosis I was actually scared shitless to have sex with anyone. I thought: 'No. That's it, I'm never having sex with anybody ever again’.”
For some people, these inhibitions persisted:
“I think it’s all mental really … I don’t put myself out there… There has been rejection and all those things before and that feeds back into not seeking any sort of sexual activity with anyone.”
On the other hand, some men described an increase in sexual activity after receiving their diagnosis. They spoke of having condomless sex with other HIV-positive partners as a liberating experience, free of the fear of contracting HIV.
“There was this exploration … It was a bit more exciting and I was being a bit more extreme and doing things that I didn't do before.”
A partner’s accepting response to HIV was important for many people who made a healthy adjustment. Some interviewees – often those in long-term relationships – reported no change to their sex lives after diagnosis:
“It was good, we were just married, so we were having sex quite often. Just normal sex.”
However, a partner who was willing to have sex without fully acknowledging the HIV and who glossed over fears of transmission did not necessarily facilitate positive adjustment. The partner needed to acknowledge HIV as part of the individual while not showing undue fear.
Accurate knowledge of transmission risks (especially U=U) helped many interviewees adjust to living with HIV:
“It does wonders for your mental health and knowing that you can’t transmit the virus.”
But factual information was not always enough to shake off deeply rooted fears:
“I still worry [about HIV transmission]. I’ve gone to workshops … and I’ve read about it a lot … even if I’m doing it the absolute safest way to have sex, I still worry…”
Peer and community support could be helpful for adjustment:
“I got to meet other positive guys, especially the older ones and just sort of learnt from their experience… it helped with that self-acceptance.”
Next week, we will be hosting an aidsmapLIVE event on HIV, sex and relationships. See the sidebar to find out how you can join the conversation on Wednesday 12 February at 6pm (UK time).
‘Frailty’ is a term doctors use to describe a general decline in physical health and a loss of reserves which can affect older people. Frailty leads to a person being less robust and less able to bounce back after an adverse event. A person with frailty may move more slowly, have lost some of their physical strength, have less energy and be less mentally agile. Frailty tends to get worse after each period of poor health or mental stress.
A Dutch study has looked more closely at frailty in people with HIV. Most participants were men in their late forties or their fifties who were taking HIV treatment and had an undetectable viral load.
During the four year study, 8% of the participants became frail. A person was considered frail if they had problems in three or more of the following areas: weight loss, low physical activity, slowness in walking, exhaustion and decreased muscle strength.
Frailty was associated with an increased risk of death. Five per cent of study participants died, of whom just under a third were frail at the beginning of the study.
Frailty was also associated with an increased risk of developing serious illnesses normally associated with ageing. These included conditions like high blood pressure, diabetes, heart disease, kidney disease or cancer. Whereas 31% of frail individuals developed a serious illness, this happened to 14% of people who were assessed as being robust.
The researchers say that doctors should assess frailty in their patients living with HIV. Physical activity is one of the most important things you can do to minimise frailty. This can help you maintain your muscle strength, keep your balance and remain as independent as possible. It’s also important to have a balanced diet, with a wide range of nutrients, and to stay socially connected.
For more information, read the NAM page 'Frailty and HIV'.
Living with visible cancer and invisible HIV
What is it like to have cancer and HIV at the same time? Are clinical services for cancer skilled in supporting patients who also have HIV?
Researchers in London aimed to find out. Their interviewees told them that both cancer and HIV had a powerful impact on their lives. But the two conditions were experienced differently.
One man said:
“I think cancer is deadly…it puts a stop to everything… HIV, I’d take my tablets for a little while and I’d bounce back”.
Cancer could be life-threatening, have debilitating symptoms and far more severe side effects from its treatment. Yet it was socially acceptable to talk about cancer, which opened the door to support and sympathetic responses from other people.
Although HIV was well managed with easy treatment, it was kept hidden for fear of rejection or discrimination. Many struggled to manage information about their HIV status while being treated for cancer. Staff on cancer wards did not always understand the need for secrecy.
One woman reflected on getting support with her cancer that she did not have in relation to HIV:
“So, there I was, able to… because a lot of these friends don’t know about the other one, so I sort of, you know, 10 years on I was getting some support that I never had got… You know I’ve been pulling on that, not in a poor me type of way, but just in allowing people to rally round.”
Nonetheless, it was not necessarily easy to talk about cancer. There was social pressure to talk about it in positive, courageous terms.
For more information, read NAM's page 'Cancer and HIV'.
NHS services for migrants
Although services in the UK’s National Health Service (NHS) are legally obliged to enforce rules on charging migrants and refugees, clinicians working in HIV, sexual and reproductive health have significant gaps in their knowledge, researchers have found.
Of the staff surveyed, 45% said they did not feel confident about their knowledge of healthcare charging and 71% wanted more training.
The survey tested respondents' knowledge and found gaps. For example, 73% knew that HIV treatment is free for all, but only 56% were aware that the treatment of the complications of HIV is also free. (However, treatment for other health conditions in people with HIV is not free of charge.)
While 64% knew that asylum seekers are eligible for free NHS care while their claim is being considered, the survey also showed that respondents were not sure of the definition of key terms, like ‘asylum seeker’, ‘refused asylum seeker’ or ‘refugee’.
Doctors and nurses’ confusion about the regulations could result in necessary health care being inappropriately delayed or denied, the researchers say.
Editors' picks from other sources
The failure-ridden search for an HIV vaccine has delivered yet another frustrating defeat. The vaccine that had moved furthest along in human testing does not work, and the $104 million trial in South Africa evaluating it has been stopped early.
“Revealing every nuance about my health with someone who doesn’t know my favorite color feels rash,” Juan Michael Porter II writes.
from The Body
HIV is an epidemic centred on Black queer folks, cisgender women, and transgender people. The same people who are often left out of conversations around barriers to treatment are the same who are most harmed by a movement centering the optimal outcome – viral suppression as a marker of health above and beyond anything else. We should take an approach to those living with HIV that centres the totality of their health, not their (detectable or undetectable) status.
19 November 2019
News from the 17th European AIDS Conference
Weight gain on HIV treatment: drug combinations, not single drugs, need to be focus of quest for cause
Weight gain after starting antiretroviral treatment probably has multiple causes but appears strongly linked to specific drugs, and to combinations of drugs, Dr Andrew Hill of the University of Liverpool told the 17th European AIDS Conference (EACS 2019) in Basel, Switzerland. He highlighted some of the problems with the ways in which the phenomenon has been studied so far and called for greater inclusion of women and black people in clinical trials of new drugs and currently prescribed agents, so that side effects of antiretroviral drugs can be studied in different population groups.
Metabolic syndrome – including obesity – developed significantly more frequently in people who received dolutegravir, tenofovir alafenamide (TAF) and emtricitabine compared to other regimens in the South African ADVANCE study, Dr Michelle Moorhouse reported at the conference.
People with suppressed viral load who switched to an integrase inhibitor-based regimen experienced only small gains in weight and do not appear to gain more weight than HIV-negative people or people who continued taking other regimens, two large cohort studies presented at the conference reported.
The integrase inhibitors dolutegravir (Tivicay, also in Triumeq and Dovato) and raltegravir (Isentress) cause changes in the structure of fat cells that may promote obesity, and can cause insulin resistance, studies of cells sampled from people living with HIV and monkeys exposed to the drugs have found.
Further evidence on the efficacy of two-drug antiretroviral regimens as simplification options for people with suppressed viral load on three-drug regimens was presented at the conference. However, German HIV specialist Professor Hans-Jürgen Stellbrink of the University of Hamburg sounded a note of caution about two-drug treatment during a discussion session at the conference, warning that “we're practising evolutionary biology on the virus by treatment, exerting the maximum selective pressure on the virus, and what I’ve learnt over 33 years is not to reduce that selective pressure on the virus.”
The conference heard about another case of a PrEP user who caught HIV despite being apparently adherent to PrEP. These cases are likely to keep on happening, Dr Hans Benjamin Hampel of Zürich University Hospital told EACS 2019, and we perhaps need to move beyond trying to establish which – if any – cases of PrEP failure have watertight evidence of 100% adherence.
The 96-week results of the DISCOVER trial, which compared the efficacy and safety of two different formulations of the antiretroviral drug tenofovir when used as daily PrEP by gay and bisexual men, were announced at the conference.
Antiretroviral treatment containing the older formulation of tenofovir (TDF) did not increase the risk of chronic kidney disease in previously untreated people with HIV at low risk for kidney disease, a large American cohort study reported at the conference.
A study presented at the recent conference comparing reported drug use among HIV-positive men attending clinics in England, Spain, Greece and Italy, has found higher rates of drug use in England than in other countries and considerably higher usage of the drugs used in chemsex (sexualised drug use) – methamphetamine, GHB/GBL, mephedrone and ketamine.
PREVENIR, the French open-label study looking at PrEP use in gay and bisexual men in the Paris region, has found that 16% of study participants either told clinicians they were stopping PrEP or disappeared from the study within a year, and that 32% had discontinued PrEP after 30 months.
The tenth edition of the European AIDS Clinical Society Guidelines was launched at the conference. Its expansion in size – from 109 pages in the ninth print edition first published two years ago to 283 pages today, plus numerous online-only supplementary tables – is evidence of the complexity of needs it seeks to address. In particular, as the average age of people with HIV increases, much of its new material has been developed with the needs of the ageing person with HIV in mind.
Anal cancer: Australian study of precancerous tissues in gay men shows little increased risk in positive men, almost no cancer cases
An Australian study of gay men recruited in community settings in Sydney, Australia has found a very high prevalence of HSIL (high-grade squamous intraepithelial lesions – precancerous changes in the cells of the anal lining that may indicate a risk of developing cancer). Yet in three years of follow-up, only one man out of 617 progressed to anal cancer, the conference heard.
The 90-90-90 targets for HIV diagnosis, treatment and viral suppression will be missed in much of eastern Europe due to poor access to HIV treatment, the conference heard on its opening day.
In his first public speech since announcing that he is living with HIV in September, Wales rugby star Gareth Thomas spoke of the need to confront HIV stigma at the conference. He spoke at a symposium organised by Gilead Sciences on the conference's opening day.
Other aidsmap news
The incidence of invasive pneumococcal disease and community-acquired pneumonia remains high among people living with HIV, investigators from the Netherlands report in Clinical Infectious Diseases. Rates of these serious lung infections were highest among people not taking anti-HIV drugs and with CD4 cell count below 500. Incidence was also much higher than that seen in the general population.
New cases of hepatitis C virus (HCV) infection among Canadian gay and bisexual men taking pre-exposure prophylaxis (PrEP) were uncommon compared with rates previously reported in Europe, according to research presented at the AASLD Liver Meeting in Boston.
Leaders of liver disease associations from Europe, the United States, Latin America and Asia issued a global call to action at the Liver Meeting in Boston, aiming to advance toward the goal of eliminating hepatitis C as a public health threat.
A recurring theme at last month’s PrEP in Europe Summit in Warsaw was that the formal approval of PrEP by regulatory agencies is not enough to make PrEP a success. Much more needs to be done in order for the people who need PrEP to actually have access to it.
Editors' picks from other sources
Men who have sex with men in Africa are more likely to test for HIV than other African men, but are significantly less likely to be on treatment or virally suppressed.
The US government says in a lawsuit that Gilead, the maker of the anti-HIV drug Truvada, owes the US public royalty money. Science reviewed the litigation filed by both sides in the dispute and spoke with leading researchers and HIV/AIDS advocates to try to clarify the arguments in this messy and long-running battle.
Pre-exposure prophylaxis (PrEP) is a vital part of ending HIV, but ads targeting people to join lawsuits are planting needless fears in patients, three leading HIV specialists write.
Earlier this month, researchers, policymakers and activists gathered in Hyderabad, India for the 50th Union World Conference on Lung Health. We picked six of the week’s most important stories.
Located in the heart of Soho, the NHS centre offers free sexual health testing and counselling services. A decade on, patients tell us why we can’t take it for granted.
07 October 2019
News from IDWeek 2019
People who started antiretroviral therapy with a regimen that included an integrase inhibitor were more likely to develop diabetes mellitus, although this increased risk differed between specific drugs, researchers reported at the IDWeek 2019 conference in Washington, DC.
An experimental two-part vaccine was not able to prevent chronic hepatitis C virus infection in a mid-stage study, according to a presentation at the conference.
Ibalizumab (Trogarzo), a long-acting monoclonal antibody that prevents HIV from entering cells, suppressed HIV for 48 weeks in people with highly resistant virus who received the drug in an expanded access programme, according to a presentation at the conference.
Other aidsmap news
The US Food and Drug Administration (FDA) last week approved tenofovir alafenamide/emtricitabine (brand name Descovy), a combination pill containing an updated version of tenofovir, as a second pre-exposure prophylaxis (PrEP) option for many people. However, the indication does not include those at risk of acquiring HIV through vaginal sex.
There is little clarity about how UK citizens living in Spain and elsewhere in the European Union will continue to get HIV treatment in the event of a no-deal Brexit, posing risks both for individuals living with HIV and the public health, according to an article in the medical journal AIDS.
Exercise reduces symptoms of depression and anxiety in people living with HIV, according to the results of a meta-analysis published in the Journal of Psychosomatic Research. The research additionally showed that aerobic exercise, training at least three times a week and exercising under professional supervision had the greatest benefits.
The proportion of nursing home residents living with HIV in the United States has increased markedly in recent years, but the facilities they are admitted to tend to be of poorer quality, researchers from Brown University report in two articles in the Journal of the American Geriatrics Society. One third of residents have some form of dementia or cognitive impairment.
In a US national sample of transgender men and transmasculine individuals, a quarter had had sex which would make them eligible for PrEP. However, only a third of those eligible had had any PrEP information from their doctor, and only 11% had actually received a PrEP prescription.
Consent, power and age difference between young black gay couples may have more effect on HIV transmission than individual characteristics, US study finds
A quite large survey of young black gay and bisexual men in two Texan cities, Houston and Dallas, has found that power dynamics between gay couples may be the most important influence on the onward spread of HIV through the black gay community, rather than factors that disadvantage individuals such as youth, poverty or low education.
Point-of-care viral load testing resulted in higher rates of switching and shorter periods on failing treatment than laboratory-based viral load testing in rural Malawi and has the potential to be "game-changing" for achievement of viral suppression goals, Médecins sans Frontières researchers report in the Journal of the International AIDS Society.
Researchers found no evidence that female sex workers in Benin engaged in higher-risk behaviours after starting pre-exposure prophylaxis (PrEP). A novel methodology was used in order to measure this: the presence of biomarkers indicating exposure to semen in vaginal samples.
Editors' picks from other sources
Stocks of the new treatment are already on the shelves of some clinics – but lingering concerns over a possible low risk of birth defects associated with this new antiretroviral have stalled the country’s switch to better medication for a second time.
from BBC News
At least 15 people in England have tested HIV positive while waiting to get a place on a trial for a pill which prevents HIV. England is the only place in the UK where places on a trial to access the drug through the NHS are restricted.
from The New York Times
Shuping Wang defied Chinese officials who tried to hide an AIDS epidemic in rural China. She helped expose the spread of HIV through shoddy facilities that bought blood from poor farmers.
from My Fabulous Disease
This is the story of the insidious influence of big pharma on our HIV/AIDS leadership and policy making, and how an experienced activist like me was tricked into delivering messages for the HIV pharma giant Gilead Sciences.