Wednesday 8 November 2017


HIV diagnoses fall sharply in England: why?

Noel Gill presenting at EACS 2017. Image credit: @caryjameslondon

HIV testing behaviour and treatment uptake are changing rapidly among men who have sex with men in some European countries, leading to new opportunities to reduce HIV incidence, the 16th European AIDS Conference (EACS 2017) heard last month in Milan.

Changes are occurring as a result of greater promotion of HIV testing, greater use of new technologies for HIV testing such as self-sampling, earlier treatment and a more widespread awareness that undetectable viral load makes a person uninfectious.

One of the earliest documented shifts has taken place in England, where surveillance has shown a dramatic reduction in HIV infections in men who have sex with men since 2014.

Dr Noel Gill of Public Health England told the conference that HIV diagnoses have fallen by 65% in London and by 48% outside London from their peak in 2014.

Dr Gill said the three most important factors contributing to the observed decline were:

  • A 50% increase in STI clinic attendance in gay men since 2011
  • An increase in the frequency of gay men’s HIV testing, with the average now 2.5 tests a year
  • 90% of those diagnosed with HIV start treatment within a year of diagnosis.

He said that a new 90-90 target could drive down the number of new infections even further, if 90% of people diagnosed with HIV started treatment within 90 days of diagnosis.

The conference also heard about how London’s busiest sexual health clinic has transformed its services in recent years to greatly increase HIV testing capacity and encourage a culture of regular sexual health screening.

A shift away from consistent condom use in Swiss men who have sex with men appears to correlate with the emergence of new information about HIV transmission risk, undetectable viral load and the effectiveness of pre-exposure prophylaxis (PrEP).

Switzerland was the first country to translate scientific evidence about the impact of undetectable viral load on sexual transmission risk into advice for doctors and people with HIV. Swiss experts said in January 2008 that HIV could not be passed on during sex by people with undetectable viral load who have no sexually transmitted infections.

A study of condom use in men who have sex with men in the Swiss HIV Cohort shows changes in condom use after 2008, with further changes after the first results of the PARTNER study and the PROUD and Ipergay studies became known.

Just because a partner has undetectable viral load, it doesn’t rule out the need for PrEP or PEP

HIV incidence among the HIV-negative gay men in the PARTNER 1 and 2 studies, due to sex with partners outside the main relationship, was high, and very high in partners who reported having condomless anal sex with non-primary partners, the conference heard.

PARTNER made headlines when in 2014, and again in 2016, the researchers confirmed that there had been no transmissions from an HIV-positive partner who was on antiretroviral therapy and virally suppressed in, by 2016, an estimated 58,213 condomless sex acts. These data allowed the researchers to establish the maximum possible likelihood of transmission, and to announce that, most likely, the chance of an HIV-positive partner with a fully suppressed viral load of below 200 copies/ml passing on HIV was zero, or statistically indistinguishable from it.

PARTNER, and other studies like Opposites Attract and HPTN 052, have provided the evidence base for the success of ‘Treatment as prevention’ and for the U=U (Undetectable = Untransmittable) campaign.

However, there were HIV infections in PARTNER: eleven of them by 2016, ten in gay men. In all cases, however, phylogenetic testing showed that the infecting virus came from someone other than the primary partner.

Levels of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) use in HIV-negative study participants were very low despite the fact that around one-third reported condomless anal intercourse with someone other than their main partner.

Presenting the results, Valentina Cambiano of University College London commented that the low level of PEP and PrEP use and the high HIV incidence seen from sex outside the main relationship were of concern.

“PrEP eligibility discussions with HIV-negative MSM [men who have sex with men] should ensure that risks from all sexual contacts are taken into consideration, and routes to securing PrEP discussed,” she added.

HPV vaccination advice from EACS

The European AIDS Clinical Society (EACS) has recommended HPV (human papillomavirus) vaccination for everyone living with HIV aged under 26 and all men who have sex with men up to the age of 40.

HPV is a sexually transmitted virus that causes genital warts, and in some forms, leads to the development of cervical, anal and oropharyngeal cancers. Anal cancer, rare in the general population, is becoming more common in people living with HIV, especially men who have sex with men.

Deborah Konopnicki of St Pierre University Hospital, Brussels presented a review of the evidence supporting vaccination against HPV in people living with HIV at the conference.

Screening for HPV-related cancers is inconsistent and for anal cancer, the choice of screening technique is still a matter of debate, she said. As for oropharyngeal cancers caused by HPV, whether to screen for these conditions is still unclear.

EACS considered several questions specific to HIV when developing its guidance:

  • Does vaccination provide protection in older people with HIV, who are more likely to have been exposed to HPV already?
  • Does vaccination provide any protection for people already exposed to HPV?
  • What vaccination schedule should be followed and which vaccine is preferred?

Only one study, the ACTG 5298 study, has looked at the effect of vaccination on protection against HPV infection in HIV-positive adults. That study found that in a predominantly male population with a median age of 47 years vaccination did not reduce persistent infection with HPV.

This finding led EACS to recommend that HPV vaccination should be offered to people with HIV aged 26 and under. EACS has also followed the British HIV Association in recommending vaccination for all men who have sex with men with HIV under the age of 40. Previous guidance issued in 2015 recommended that doctors should follow national guidance on HPV vaccination.

Although EACS states that the efficacy of the vaccine is questionable in people who have already been exposed to HPV, Deborah Konopnicki said it is still plausible that vaccination could improve protection against HPV-associated disease.

The ACTG A5240 study showed that in women already seropositive for any of the HPV types included in the quadrivalent vaccine, vaccination resulted in a substantial increase in HPV antibody titres (levels) (+1.5 log10 IU/ml).

There is also some evidence from studies in HIV-negative women and men who have sex with men that vaccination after the treatment of HPV-associated cervical or anal lesions is associated with reductions in recurrence of lesions. Two ongoing studies are likely to provide further information on vaccination’s role in the prevention of recurrence in people living with HIV.

Vaccination results in greater antibody responses in women living with HIV who already have undetectable HIV viral load at the time of the first vaccination, probably because viral suppression permits immune restoration.

EACS recommends the 9-valent HPV vaccine if available (active against nine common types of HPV). Dr Konopnicki noted that there is no evidence in people living with HIV to support anything less than a 3-dose vaccination schedule, although several studies in young women have shown that a single vaccination is just as immunogenic as multiple vaccinations.

Lack of increase in PrEP usage in Europe over the past year

Teymur Noori presenting at EACS 2017. Image credit: @caryjameslondon

A study of men who have sex with men conducted by the European Centre for Disease Prevention and Control (ECDC) in collaboration with the gay contact site Hornet has found that pre-exposure prophylaxis (PrEP) usage has not increased, on average, among its respondents since a survey last year.

The survey found that 10% of its respondents were currently taking PrEP, though this varied from hardly any in some countries to 17% in the case of Ukraine.

Participants were generally young; 75% were under 40 and 28% under 25. Approximately half were being prescribed PrEP by a doctor, the remainder were buying PrEP drugs online or obtaining them from friends or by requesting post-exposure prophylaxis (PEP).

Although PrEP was slowly being introduced in more countries, progress was slow, Teymur Noori of ECDC said. The cost of PrEP was overwhelmingly cited as the main barrier to adopting it, with two-thirds of 36 nations in the EU/EEA mentioning cost as a principal barrier. In the face of national health systems’ unwillingness to spend on PrEP, the survey provided evidence that men who have sex with men throughout the European region were attempting to access it in other ways.

Hepatitis C test-and-treat in Switzerland

A systematic policy of test-and-treat cured 99% of men who have sex with men with hepatitis C in the Swiss HIV Cohort in an 8-month period and reduced the prevalence of hepatitis C by almost two-thirds, Dominique Braun of the University Hospital, Zurich, reported at the conference.

Reducing onward transmission and prevalence of hepatitis C virus (HCV) requires a reduction in the number of people with chronic HCV infection and a reduction in risk behaviours. Chemsex – especially the use of drugs and sharing of injecting equipment during sex – and group sex are strongly implicated in the increase in hepatitis C in men who have sex with men.

The Swiss HIV Cohort has seen a 20-fold increase in the prevalence of HCV in men who have sex with men since 1996, with the greatest increase occurring since 2008, in common with other western European countries.

Swiss researchers designed an intervention study in which they sought to diagnose all men who have sex with men with HIV and HCV co-infection already in HIV care in Switzerland, treat all those with genotype 1 or 4 infection and prevent onward transmission and reinfection through behavioural intervention.

All men with genotype 1 or 4 infection were offered immediate treatment with a course of grazoprevir/elbasvir (Zepatier), with or without ribavirin, for varying durations of treatment depending on genotype, previous treatment history and baseline resistance profile.

Of the 177 people diagnosed with chronic HCV infection, 122 took part in the study (34 received treatment elsewhere, 11 had a genotype other than 1 or 4, 6 had contraindications for treatment and the remainder were either lost to follow-up or unwilling to take part in the study).

All participants except one were cured and no serious drug-related adverse events were reported.

Sixty-eight men recruited to the study reported condomless sex with non-regular partners. Of these men, 51 agreed to take part in a four-session behavioural intervention devised by Professor Dunja Nicca of Zurich University that accompanied the treatment phase of the study.

The first session focused on emotional responses to safe sex problems, the second on individualised solutions, the third on developing a personal risk reduction plan and the fourth session a reflection on the post-treatment achievement of hepatitis C cure and how to maintain it.

The overall completion rate of the behavioural intervention was 90%. No cases of reinfection have been identified to date.

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