Sustained Reduction in Sexual Behavior that May Pose a Risk of HIV Transmission Following Diagnosis During Early HIV Infection Among Gay Men in Vancouver, British Columbia

Ethical considerations for HIV remission clinical research involving participants diagnosed during acute HIV infection

HIV remission clinical researchers are increasingly seeking study participants who are diagnosed and treated during acute HIV infection—the brief period between infection and the point when the body creates detectable HIV antibodies. This earliest stage of infection is often marked by flu-like illness and may be an especially tumultuous period of confusion, guilt, anger, and uncertainty. Such experiences may present added ethical challenges for HIV research recruitment, participation, and retention. The purpose of this paper is to identify potential ethical challenges associated with involving acutely diagnosed people living with HIV in remission research and considerations for how to mitigate them. We identify three domains of potential ethical concern for clinicians, researchers, and ethics committee members to consider: 1) Recruitment and informed consent; (2) Transmission risks and partner protection; and (3) Ancillary and continuing care. We discuss each of these domains with the aim of inspiring further work to advance the ethical conduct of HIV remission research. For example, experiences of confusion and uncertainty regarding illness and diagnosis during acute HIV infection may complicate informed consent procedures in studies that seek to recruit directly after diagnosis. To address this, it may be appropriate to use staged re-consent procedures or comprehension assessment. Responsible conduct of research requires a broad understanding of acute HIV infection that encompasses its biomedical, psychological, social, and behavioral dimensions. We argue that the lived experience of acute HIV infection may introduce ethical concerns that researchers and reviewers should address during study design and ethical approval.

Change in Condom Use in Populations Newly Aware of HIV Diagnosis in the United States and Canada: A Systematic Review and Meta-Analysis

HIV-infected individuals "aware" of their infection are more likely to use condoms, compared to HIV-infected "unaware" persons. To quantify this likelihood, we undertook a systematic review and meta-analysis of U.S. and Canadian studies. Twenty-one eligible studies included men who have sex with men (MSM; k = 15), persons who inject drugs (PWID; k = 2), and mixed populations of high-risk heterosexuals (HRH; k = 4). Risk ratios (RR) of "not always using condoms" with partners of any serostatus were lower among aware MSM (RR 0.44 [not significant]), PWID (RR 0.70) and HRH (RR 0.27); and, in aware MSM, with partners of HIV-uninfected or unknown status (RR 0.46). Aware individuals had lower "condomless sex likelihood" with HIV-uninfected or unknown status partners (MSM: RR 0.58; male PWID: RR 0.44; female PWID: RR 0.65; HRH: RR 0.35) and with partners of any serostatus (MSM only, RR 0.72). The association diminished over time. High risk of bias compromised evidence quality.

Sexual behaviour change following HIV testing services: a systematic review and meta-analysis

INTRODUCTION

Learning one's HIV status through HIV testing services (HTS) is an essential step toward accessing treatment and linking to preventive services for those at high HIV risk. HTS may impact subsequent sexual behaviour, but the degree to which this varies by population or is true in the setting of contemporary HIV prevention activities is largely unknown. As part of the 2019 World Health Organization Consolidated Guidelines on HTS, we undertook a systematic review and meta-analysis to determine the effect of HTS on sexual behaviour.

METHODS

We searched nine electronic databases for studies published between July 2010 and December 2019. We included studies that reported on at least one outcome (condom use [defined as the frequency of condom use or condom-protected sex], number of sex partners, HIV incidence, STI incidence/prevalence). We included studies that prospectively assessed outcomes and that fit into one of three categories: (1) those evaluating more versus less-intensive HTS, (2) those of populations receiving HTS versus not and (3) those evaluating outcomes after versus before HTS. We conducted meta-analyses using random-effects models.

RESULTS AND DISCUSSION

Of 29 980 studies screened, 76 studies were included. Thirty-eight studies were randomized controlled trials, 36 were cohort studies, one was quasi-experimental and one was a serial cross-sectional study. There was no significant difference in condom use among individuals receiving more-intensive HTS compared to less-intensive HTS (relative risk [RR]=1.03; 95% CI: 0.99 to 1.07). Condom use was significantly higher after receiving HTS compared to before HTS for individuals newly diagnosed with HIV (RR = 1.65; 95% CI: 1.36 to 1.99) and marginally significantly higher for individuals receiving an HIV-negative diagnosis (RR = 1.63; 95% CI: 1.01 to 2.62). Individuals receiving more-intensive HTS reported fewer sex partners at follow-up than those receiving less-intensive HTS, but the finding was not statistically significant (mean difference = -0.28; 95% CI: -3.66, 3.10).

CONCLUSIONS

Our findings highlight the importance of using limited resources towards HTS strategies that focus on early HIV diagnosis, treatment and prevention services rather than resources dedicated to supplementing or enhancing HTS with additional counselling or other interventions.

The Need and Desire for Mental Health and Substance Use-Related Services Among Clients of Publicly Funded Sexually Transmitted Infection Clinics in Vancouver, Canada

CONTEXT

Sexually transmitted infections (STI) and mental health and substance use (MHSU) disorders all occur at elevated rates in sexual and gender minorities. These overlapping epidemics, or syndemics, are exacerbated by challenges these same populations face in accessing sexual/gender minority-affirming services. Many publicly funded STI clinics are a low barrier and provide sexual minority-competent care. These sites therefore may be uniquely situated to address clients' MHSU-related needs.

OBJECTIVE

We characterize the need and desire for MHSU services among STI clinic clients.

DESIGN, SETTING, PARTICIPANTS

We conducted a waiting room survey at 6 STI clinics in Metro Vancouver, Canada.

MAIN OUTCOME MEASURES

We calculated the proportion of clients with self-reported unmet MHSU needs in the previous 12 months and, among these clients, barriers to accessing MHSU services and desire for MHSU services within the STI clinic. We also examined social disparities in barriers to accessing MHSU services.

RESULTS

Among 1115 respondents-65% of whom were sexual minorities-39% reported a recent need for MHSU-related care, most frequently in relation to anxiety (29%), depression (26%), substance use (10%), or suicide ideation (7%). Seventy-two percent of this group had not yet talked to a provider about their concern. Common barriers included shame (26%) and inability to afford the service (24%). Eighty-three percent of clients with unmet MHSU needs indicated that they were comfortable discussing MHSU concerns with an STI clinic provider, and 94% expressed desire to receive MHSU assessments, referrals, or counseling in the STI clinic. Sexual and gender minorities and those attending a suburban clinic were more likely to report barriers to accessing MHSU services.

CONCLUSIONS

More than a quarter of STI clinic clients report unmet MHSU health care needs; moreover, these clients report high levels of comfort with and desire to discuss MHSU concerns with STI clinic providers. Sexually transmitted infections clinics are thus opportune sites for syndemic service integration.

The potential impact of initiating antiretroviral therapy with integrase inhibitors on HIV transmission risk in British Columbia, Canada

BACKGROUND

Available agents within the integrase strand-transfer inhibitor (INSTI) class have been shown to lead to a faster decay in viral load than other regimens. Therefore, we estimated the potential reduction in HIV transmission risk among antiretroviral-naïve individuals initiating on INSTI-based antiretroviral therapy (ART), focusing on the gay, bisexual and other men who have sex with men (gbMSM) population and various degrees of sexual activity.

METHODS

Using two mathematical models that estimate the HIV transmission risk corresponding to different viral loads, we estimated the average probability of HIV transmission per risky contact for gbMSM during the six months post-ART initiation, stratified by stage of HIV infection, viral load at ART initiation and type of first-line ART (i.e., INSTI or non-INSTI-based ART). This study focused individuals who initiated ART between 2011 and 2016 with at least one year of follow-up in British Columbia, Canada.

FINDINGS

Time to first virologic suppression for INSTI-based regimens was 21.4 days (95% credible interval (CI) 19.9-23.2), compared to 58.6 days (95% CI 54.1-62.2) for non-INSTI regimens. We showed that INSTI-based regimens could reduce the HIV transmission risk by at least 25% among those with viral load ≥ 5 log₁₀ copies/mL at ART initiation.

INTERPRETATION

Initiating ART on INSTI-based regimens has the potential to reduce HIV transmission risk among individuals with high baseline viral load levels, especially among those with high levels of sexual activity.

FUNDING

The British Columbia Ministry of Health, the Canadian Institutes of Health Research, and the Michael Smith Foundation for Health Research.

A novel Bayesian approach to predicting reductions in HIV incidence following increased testing interventions among gay, bisexual and other men who have sex with men in Vancouver, Canada

Increasing HIV testing rates among high-risk groups should lead to increased numbers of cases being detected. Coupled with effective treatment and behavioural change among individuals with detected infection, increased testing should also reduce onward incidence of HIV in the population. However, it can be difficult to predict the strengths of these effects and thus the overall impact of testing. We construct a mathematical model of an ongoing HIV epidemic in a population of gay, bisexual and other men who have sex with men. The model incorporates different levels of infection risk, testing habits and awareness of HIV status among members of the population. We introduce a novel Bayesian analysis that is able to incorporate potentially unreliable sexual health survey data along with firm clinical diagnosis data. We parameterize the model using survey and diagnostic data drawn from a population of men in Vancouver, Canada. We predict that increasing testing frequency will yield a small-scale but long-term impact on the epidemic in terms of new infections averted, as well as a large short-term impact on numbers of detected cases. These effects are predicted to occur even when a testing intervention is short-lived. We show that a short-lived but intensive testing campaign can potentially produce many of the same benefits as a campaign that is less intensive but of longer duration.