Sexual behaviour of people living with HIV in London: implications for HIV transmission

Impact of early antiretroviral treatment on sexual behaviour: a randomised comparison

Background:

Antiretroviral treatment (ART) reduces HIV infectiousness but the effect of early ART on sexual behaviour is unclear.

Methods:

We assessed, within the START randomized trial that enrolled HIV-positive adults with CD4⁺ cell count greater than 500 cells/μl, the effect of early (immediate) versus deferred ART on: condomless sex with HIV-serodifferent partners (CLS-D); all condomless sex (CLS); HIV transmission-risk sex (CLS-D-HIV risk, defined as CLS-D and: not on ART or started ART <6 months ago or viral load greater than 200 copies/ml or no viral load in past 6 months), during 2-year follow-up. Month-12 CLS-D (2010–2014) was the primary outcome.

Results:

Among 2562 MSM, there was no difference between immediate and deferred arms in CLS-D at month 12 [12.6 versus 13.1%; difference (95% CI): −0.4% (−3.1 to 2.2%), P = 0.75] or month 24, or in CLS. Among 2010 heterosexual men and women, CLS-D at month 12 tended to be higher in the immediate versus deferred arm [10.8 versus 8.3%; difference:2.5% (−0.1 to 5.2%), P = 0.062]; the difference was greater at month 24 [9.3 versus 5.6%; difference: 3.7% (1.0 to 6.4%), P = 0.007], at which time CLS was higher in the immediate arm (20.7 versus 15.7%, P = 0.013). CLS-D-HIV risk at month 12 was substantially lower in the immediate versus deferred arm for MSM [0.2 versus 11%; difference: −10.7% (−12.5 to −8.9%), P < 0.001] and heterosexuals [0.6% versus 7.7%; difference: −7.0% (−8.8 to −5.3%), P < 0.001], because of viral suppression on ART.

Conclusion:

A strategy of early ART had no effect on condomless sex with HIV-serodifferent partners among MSM, but resulted in modestly higher prevalence among heterosexuals. However, among MSM and heterosexuals, early ART resulted in a substantial reduction in HIV-transmission-risk sex, to a very low absolute level.

High-risk behaviours, and their associations with mental health, adherence to antiretroviral therapy and HIV parameters, in HIV-positive men who have sex with men

Objectives

To investigate the patterns and frequency of multiple risk behaviours (alcohol, drugs, smoking, higher risk sexual activity) among men who have sex with men (MSM) living with HIV.

Methods

Cross sectional study.

Results

147 out of 819 HIV‐positive MSM exhibited a high‐risk phenotype (defined as >3 of smoking, excess alcohol, sexually transmitted infection and recent recreational drug use). This phenotype was associated with younger age, depressive symptoms and <90% adherence in multivariable logistic regression.

Conclusion

In a cohort of MSM, a small, but significant proportion exhibited multiple concurrent risk behaviours.

Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Background

More than 100,000 people in the UK are living with a human immunodeficiency virus (HIV) infection. There are currently estimated to be around 4000 people newly infected in the UK per year, mostly men who have sex with men (MSM). It has become increasingly clear that antiretroviral therapy (ART) used to treat people infected with HIV also has a profound effect on infectivity. At the initiation of the programme, it was the policy in the UK to initiate ART in people when their cluster of differentiation 4 (CD4) count was approaching 350/µl.

Objectives

To assess what would be the effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis among MSM, taking into account the potential reductions in new infections.

Design

We calibrated an individual-based model of HIV transmission, progression and the effect of ART in MSM, informed by a series of studies on sexual behaviour in relation to ART use and the transmission risk in people with viral suppression on ART, and by surveillance data collected by Public Health England.

Setting, participants and interventions

The series of studies used to inform the model included (1) the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study, a cross-sectional self-administered questionnaire study of people diagnosed with HIV attending eight HIV outpatient clinics in the UK (2011–12); (2) the Cognitive Impairment in People with HIV in the European Region (CIPHER) study, a study of levels of neurocognitive impairment in HIV-positive ASTRA participants and people from HIV clinics in Rome, Copenhagen and Minsk; (3) the Attitudes to, and Understanding of, Risk of Acquisition of HIV (AURAH) study, a cross-sectional self-administered questionnaire study of individuals who have not been diagnosed as HIV-positive attending 20 genitourinary medicine clinics across the UK (2013–14); (4) a substudy of sexual behaviour among individuals enrolled in an open-label multicentre international randomised trial (from 2013) of immediate versus deferred ART (to CD4 cell counts of 350/µl) in people with CD4 cell counts of > 500/µl [the Strategic Timing of Antiretroviral Therapy (START) trial]; and (5) Partners of People on ART: a new Evaluation of the Risks (PARTNER), an observational multicentre longitudinal study of HIV serodifferent heterosexual and MSM couples, in which the HIV-positive partner is on ART (2010–14).

Main outcome measures

The main outcome measures were the clinical effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis.

Results

Based on data from studies (i)–(v), we estimated from our modelling work that increases in condomless sex (CLS) among MSM as a whole may explain the increase in HIV infection incidence in MSM epidemics over a time when ART coverage and viral suppression increased, demonstrating the limiting effects of non-condom use on the HIV epidemic among MSM. Accordingly, an increase in the overall proportion of MSM living with HIV who are virally suppressed on ART from the current level of < 60% to 90% without increases in CLS was required to achieve a reduction in the incidence of HIV among MSM to < 1 per 1000 person-years. The incremental cost-effectiveness ratio associated with the fourfold increase in levels of HIV testing and ART at diagnosis required to provide this increase from < 60% to 90% was £20,000 if we assumed continuation of current ART prices. However, this value falls to £3500 if we assume that ART prices will fall to 20% of their current cost as a result of the introduction of generic drugs. Therefore, our evaluation suggests that ART initiation at diagnosis is likely to be highly cost-effective in MSM at a population level, particularly accounting for future lower ART costs as generic drugs are used. The impact will be much greater if levels of HIV testing can be enhanced.

Limitations

It was necessary to make some assumptions beyond the available data in order to extrapolate cost-effectiveness through modelling.

Conclusions

Our findings suggest that ART initiation at diagnosis is likely to be cost-effective in MSM. Of note, after this programme of work was completed, results from the main START trial demonstrated benefit in ART initiation even in people with CD4 cell counts of > 500/µl, supporting ART initiation in people diagnosed with a HIV infection.

Future work

There is a need for future research into the means of increasing the frequency with which MSM test for HIV.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Condomless sex in HIV-diagnosed men who have sex with men in the UK: prevalence, correlates, and implications for HIV transmission

Objective

HIV transmission is ongoing among men who have sex with men (MSM) in the UK. Sex without a condom (condomless sex, CLS) is the main risk factor. We investigated the prevalence of and factors associated with types of CLS.

Methods

Cross-sectional questionnaire study in UK HIV clinics in 2011/2012 (ASTRA). MSM diagnosed with HIV for ≥3 months reported on anal and vaginal sex, CLS with HIV-serodifferent partners (CLS-D) and CLS with HIV-seroconcordant (CLS-C) partners in the previous 3 months. Mutually exclusive sexual behaviours were as follows: (1) Higher HIV risk CLS-D (not on antiretroviral therapy (ART) or clinic-recorded viral load(VL) >50 c/mL), (2) Other CLS-D, (3) CLS-C without CLS-D, (4) Condom-protected sex only and (5) No anal or vaginal sex. Associations were examined of sociodemographic, HIV-related, lifestyle, and other sexual measures with the five categories of sexual behaviour. We examined the prevalence of higher HIV risk CLS-D incorporating (in addition to ART and VL) time on ART, ART non-adherence, and recent sexually transmitted infections (STIs).

Results

Among 2189 HIV-diagnosed MSM (87% on ART), prevalence of any CLS in the past 3 months was 38.2% (95% CI 36.2% to 40.4%) and that of any CLS-D was 16.3% (14.8%–17.9%). The five-category classification was as follows: (1) Higher HIV risk CLS-D: 4.2% (3.5% to 5.2%), (2) Other CLS-D: 12.1% (10.8% to 13.5%), (3) CLS-C without CLS-D: 21.9% (20.2% to 23.7%), (4) Condom-protected sex only: 25.4% (23.6% to 27.3%) and (5) No anal or vaginal sex: 36.4% (34.3% to 38.4%). Compared with men who reported condom-protected sex only, MSM who reported any CLS in the past 3 months had higher prevalence of STIs, chemsex-associated drug use, group sex, higher partner numbers, and lifetime hepatitis C. Prevalence of higher HIV risk CLS-D ranged from 4.2% to 7.5% according to criteria included.

Conclusion

CLS was prevalent among HIV-diagnosed MSM, but CLS-D with higher HIV transmission risk was overall low. CLS-D is no longer the most appropriate measure of HIV transmission risk behaviour among people with diagnosed HIV; accounting for VL is important.

Sexual behaviour among people with HIV according to self-reported antiretroviral treatment and viral load status

OBJECTIVE

To assess, among people with HIV, the association of self-reported antiretroviral treatment (ART) and viral load status with condomless sex with an HIV-serodifferent partner (CLS-D).

DESIGN

Cross-sectional study of 3258 HIV-diagnosed adults in the United Kingdom, 2011-2012.

METHODS

CLS-D in the past 3 months and self-reported ART/viral load were ascertained by questionnaire. Clinic-recorded viral load was documented. HIV-transmission risk sex (CLS-D-HIV-risk) was defined as CLS-D together with either not on ART or clinic-recorded viral load more than 50 copies/ml.

RESULTS

Of 3178 participants diagnosed more than 3 months ago, 2746 (87.9%) were on ART, of whom self-reported viral load was '50 copies/ml/ or less/undetectable' for 78.4%; 'more than 50 copies/ml/detectable' for 8.3%; 'do not know/missing' for 13.3%. CLS-D prevalence was 14.9% (326/2189), 6.4% (23/360) and 10.7% (67/629) among men who have sex with men, heterosexual men and women, respectively. Among men who have sex with men, CLS-D prevalence was 18.8% among those not on ART; 15.2% among those on ART with undetectable self-reported viral load; 9.8% among those on ART without undetectable self-reported viral load. Compared with 'on ART with undetectable self-reported viral load', prevalence ratios (95% confidence interval) adjusted for demographic/HIV-related factors were: 0.66 (0.45, 0.95) for 'on ART without undetectable self-reported viral load', and 1.08 (0.78, 1.49) for 'not on ART' (global P = 0.021). Among heterosexual men and women (combined), ART/self-reported viral load was not associated with CLS-D [corresponding adjusted prevalence ratios: 1.14 (0.73, 1.79) for 'on ART without undetectable self-reported viral load'; 0.88 (0.44, 1.77) for 'not on ART', P = 0.77]. CLS-D-HIV-risk prevalence was 3.2% among all participants; 16.1% for 'not on ART'; 0.6% for 'on ART with undetectable self-reported viral load; 4.2% for 'on ART without undetectable self-reported viral load.'

CONCLUSION

Use of ART was not associated with increased prevalence of CLS-D, and was associated with greatly reduced prevalence of HIV-transmission risk sex.

Factors associated with pre-ART loss-to-follow up in adults in rural KwaZulu-Natal, South Africa: a prospective cohort study

BACKGROUND

Timely initiation of antiretroviral treatment (ART) requires sustained engagement in HIV care before treatment eligibility. We assessed loss to follow-up (LTFU) correlates in HIV-positive adults accessing HIV treatment and care, not yet ART-eligible (CD4 >500 cells/mm(3)).

METHODS

This was a sub-study of a prospective cohort study (focusing on sexual behaviour) in an area of high HIV prevalence and widespread ART availability in rural KwaZulu-Natal, South Africa. Psychosocial, clinical and demographic data were collected at recruitment from individuals with CD4 >500 cells/mm(3). LTFU was defined as not attending clinic within 13 months of last visit or before death. Individuals starting ART were censored at ART initiation. Data were collected between January 2009 and January 2013. Analysis used Competing Risks regression.

RESULTS

Two hundred forty-seven individuals (212 females) were recruited (median follow-up 2.13 years, total follow-up 520.15 person-years). 86 remained in pre-ART care (34.8 %), 94 were LTFU (38.1 %), 58 initiated ART (23.5 %), 7 died (2.8 %), 2 transferred out (0.8 %). The LTFU rate was 18.07 per 100 person-years (95 % CI 14.76-21.12). LTFU before a competing event was 13.5 % at one and 34.4 % at three years. Lower LTFU rates were significantly associated with age (>37 versus ≤37 years: adjusted sub-Hazard ratio (aSHR) 0.51, 95 % CI 0.30-0.87), openness with family/friends (a little versus not at all, aSHR 0.81, 95 % CI 0.45-1.43; a lot versus not at all, aSHR 1.57, 95 % CI 0.94-2.62), children (0 versus 4+, aSHR 0.68, 95 % CI 0.24-1.87; 1 versus 4+, aSHR 2.05 95 % CI 1.14-3.69, 2 versus 4+; aSHR 1.71, 95 % CI 0.94-3.09; 3 versus 4a, aSHR 1.14, 95 % CI 0.57-2.30), previous CD4 counts (1 versus 0, aSHR 0.81, 95 % CI 0.45-1.43; 2+ versus 0, aSHR 0.43, 95 % CI 0.25-0.73), and most recent partner HIV status (not known versus HIV-positive, aSHR 0.77, 95 % CI 0.50-1.19; HIV-negative versus HIV-positive, aSHR 2.40, 95 % CI 1.18-4.88). The interaction between openness with family/friends and HIV partner disclosure was close to significance (p = 0.06). Those who had neither disclosed to partners nor were open with family/friends had lowest LTFU rates.

CONCLUSIONS

Strategies to retain younger people in pre-ART care are required. How openness with others, partner HIV status and disclosure, and children relate to LTFU needs further exploration.

A systematic review of post-migration acquisition of HIV among migrants from countries with generalised HIV epidemics living in Europe: mplications for effectively managing HIV prevention programmes and policy

Background

Migrant populations from countries with generalised HIV epidemics make up a significant proportion of all HIV/AIDS cases in many European Union and European Economic Area (EU/EEA) countries, with heterosexual transmission the predominant mode of HIV acquisition. While most of these infections are diagnosed for the first time in Europe, acquisition is believed to have predominantly occurred in the home country. A proportion of HIV transmission is believed to be occurring post-migration, and many countries may underestimate the degree to which this is occurring. Our objectives were to review the literature estimating the proportion of migrants believed to have acquired their HIV post-migration and examine which EU member states are able to provide estimates of probable country of HIV acquisition through current surveillance systems.

Methods

A systematic review was undertaken to gather evidence of sexual transmission of HIV within Europe among populations from countries with a generalised epidemic. In addition, national surveillance focal points from 30 EU/EEA Member States were asked to complete a questionnaire about surveillance methods and monitoring of the likely place of HIV acquisition among migrants.

Results & discussion

Twenty-seven papers from seven countries were included in the review and 24 countries responded to the survey. Estimates of HIV acquisition post-migration ranged from as low as 2 % among sub Saharan Africans in Switzerland, to 62 % among black Caribbean men who have sex with men (MSM) in the UK. Surveillance methods for monitoring post-migration acquisition varied across the region; a range of methods are used to estimate country or region of HIV acquisition, including behavioural and clinical markers. There is little published evidence addressing this issue, although Member States highlight the importance of migrant populations in their epidemics.

Conclusions

There is post-migration HIV acquisition among migrants in European countries but this is difficult to quantify accurately with current data. Migrant MSM appear at particular risk of HIV acquisition post-migration. Countries that identify migrants as an important part of their HIV epidemic should focus on using an objective method for assigning probable country of HIV acquisition. Robust methods to measure HIV incidence should be considered in order to inform national prevention programming and resource allocation.

The association between self-reported stigma and loss-to-follow up in treatment eligible HIV positive adults in rural Kwazulu-Natal, South Africa

BACKGROUND

The relationship between loss-to-follow-up (LTFU) in HIV treatment and care programmes and psychosocial factors, including self-reported stigma, is important to understand. This prospective cohort study explored stigma and LTFU in treatment eligible adults who had yet not started antiretroviral therapy (ART).

METHODS

Psychosocial, clinical and demographic data were collected at a baseline interview. Self-reported stigma was measured with a multi-item scale. LTFU was defined as not attending clinic in the 90 days since last appointment or before death. Data was collected between January 2009 and January 2013 and analysed using Cox Regression.

RESULTS

380 individuals were recruited (median time in study 3.35 years, total time at risk 1065.81 person-years). 203 were retained (53.4%), 109 were LTFU (28.7%), 48 had died and were not LTFU at death (12.6%) and 20 had transferred out (5.3%). The LTFU rate was 10.65 per 100 person-years (95% CI: 8.48-12.34). 362 individuals (95.3%) started ART. Stigma total score (categorised in quartiles) was not significantly associated with LTFU in either univariable or multivariable analysis (adjusting for other variables in the final model): second quartile aHR 0.77 (95%CI: 0.41-1.46), third quartile aHR 1.20(95%CI: 0.721-2.04), fourth quartile aHR 0.62 (95%CI: 0.35-1.11). In the final multivariable model, higher LTFU rates were associated with male gender, increased openness with friends/family and believing that community problems would be solved at higher levels. Lower LTFU rates were independently associated with increased year of age, greater reliance on family/friends, and having children.

CONCLUSIONS

Demographic and other psychosocial factors were more closely related to LTFU than self-reported stigma. This may be consistent with high levels of social exposure to HIV and ART and with stigma affecting LTFU less than other stages of care. Research and clinical implications are discussed.

The 'Antiretrovirals, Sexual Transmission Risk and Attitudes' (ASTRA) study. Design, methods and participant characteristics

Life expectancy for people diagnosed with HIV has improved dramatically however the number of new infections in the UK remains high. Understanding patterns of sexual behaviour among people living with diagnosed HIV, and the factors associated with having condom-less sex, is important for informing HIV prevention strategies and clinical care. In addition, in view of the current interest in a policy of early antiretroviral treatment (ART) for all people diagnosed with HIV in the UK, it is of particular importance to assess whether ART use is associated with increased levels of condom-less sex. In this context the ASTRA study was designed to investigate current sexual activity, and attitudes to HIV transmission risk, in a large unselected sample of HIV-infected patients under care in the UK. The study also gathered background information on demographic, socio-economic, lifestyle and disease-related characteristics, and physical and psychological symptoms, in order to identify other key factors impacting on HIV patients and the behaviours which underpin transmission. In this paper we describe the study rationale, design, methods, response rate and the demographic characteristics of the participants. People diagnosed with HIV infection attending 8 UK HIV out-patient clinics in 2011-2012 were invited to participate in the study. Those who agreed to participate completed a confidential, self-administered pen-and-paper questionnaire, and their latest CD4 count and viral load test results were recorded. During the study period, 5112 eligible patients were invited to take part in the study and 3258 completed questionnaires were obtained, representing a response rate of 64% of eligible patients. The study includes 2248 men who have sex with men (MSM), 373 heterosexual men and 637 women. Future results from ASTRA will be a key resource for understanding HIV transmission within the UK, targeting prevention efforts, and informing clinical care of individuals living with HIV.

Association between knowledge of HIV-positive status or use of antiretroviral therapy and high-risk transmission behaviors: systematic review

To systematically review the evidence on the association between knowledge of HIV-positive status or use of antiretroviral therapy (ART) and high-risk transmission behaviors, we searched Ovid MEDLINE from 2004 to February 2012 and the Cochrane Library Database through the first quarter of 2012. Four observational studies meeting inclusion criteria addressed HIV-positive status and seven addressed the use of ART and effects on behavior. Studies including both average and high-risk populations were conducted in developed countries and were rated at least fair quality. Overall, knowledge of HIV-positive status was associated with less engagement in high-risk transmission behaviors, and the use of ART was not found to increase participation in high-risk transmission behaviors by HIV-positive individuals.

Reproductive assistance in HIV serodiscordant couples

BACKGROUND

Three quarters of individuals infected with human immunodeficiency virus (HIV) are in their reproductive years and may consider pregnancy planning. Techniques have been developed which can minimize the risk of HIV transmission in these couples, and the current literature on this topic is reviewed here.

METHODS

We reviewed the literature for the following topics: risk of HIV transmission, effects of HIV infection on fertility, reproductive assistance in industrialized and low-income countries, pre-exposure chemoprophylaxis (PrEP) and timed intercourse in HIV-discordant couples for both male and female positivity. Relevant publications were identified through searches of the EMBASE Medline and PubMed databases, the Google-indexed scientific literature and periodic specialized magazines from the on-line Library Service of the University of Milan, Italy.

RESULTS

In serodiscordant couples in which the man is positive, the primary method used to prevent HIV transmission is 'sperm washing', followed by IUI or IVF. Data show that sperm washing in HIV-positive men has not produced seroconversion in women or their offspring; however, the evidence is limited. Recently, increasing evidence describing PrEP for HIV prevention has been published and PrEP could be an alternative to ART for fertile couples. Usually HIV-infected women undergo self-insemination around the time of ovulation. Few studies have been published on IVF outcome in HIV-infected women.

CONCLUSIONS

Assisted reproduction programmes should be integrated into global public health services against HIV. For HIV serodiscordant couples with infected men, sperm washing should be the first choice. However, timed intercourse and PrEP for HIV prevention has been reported. Recent data highlight the possible impairment of fertility in HIV-infected women. Efforts to design a multicentric study should be strengthened.

Prevalence of human immunodeficiency virus infection among transgender men in Rawalpindi (Pakistan)

BACKGROUND

Transgender males are at high risk for sexually transmitted diseases including AIDS caused by the notorious Human Immunodeficiency Virus (HIV), yet little consideration is given by the policy makers, researchers and non-governmental organizations (NGOs) towards this sensitive issue in Pakistan.

METHODS

In this study, we have investigated the prevalence of HIV infection among 306 transgender males with a median age of 29 years (range 15-64 years) residing in Rawalpindi, Pakistan. Rapid HIV antibody-screening methods including the strip test and Enzyme Linked Immuno-absorbent tests were employed to detect HIV antibodies among the subjects. For further confirmation, Polymerase Chain Reaction (PCR) was carried out. Statistical analytical techniques utilized included logistic regression and chi-square.

RESULTS

HIV-1 was found to be the predominant viral subtype. PCR confirmed 21.6% (Confidence Interval 0.17-0.26) of the respondents were reported being HIV positive. 15.7% of the transgender men who shave at home and 13.7% of the transgender men who were educated below 5th grade were found to have HIV.

CONCLUSION

This study shows a very high prevalence of HIV among transgender males. Unawareness among these individuals about the ramifications of this infection owes largely to lack of education. The spread rate is alarming and HIV epidemic is imminent if awareness is not widespread.

Behavioral surveillance study: sexual risk taking behaviour in UK HIV outpatient attendees

This study aimed to determine demographic, behavioural and self-report disease/treatment variables among HIV-infected individuals (n = 666) that predict unprotected intercourse with a partner of unknown/discordant status. Sexual risk behaviour was reported by 12.8%. In multivariable analysis, risk was more likely to be reported by gay men compared to women or heterosexual men, and for those with higher psychological symptom burden. Psychological symptoms should be assessed and managed in the HIV outpatient setting to ensure integrated care that enhances prevention.

Characteristics of HIV epidemics driven by men who have sex with men and people who inject drugs

PURPOSE OF REVIEW

To highlight the latest developments in mathematical transmission modelling of HIV epidemics among men who have sex with men (MSM) and people who inject drugs (PWID).

RECENT FINDINGS

Mathematical approaches have been applied to a wide range of topics in recent HIV research. Epidemiological models have evaluated past and forecasted future trends in prevalence and incidence, evaluated innovative behaviour modification strategies and public health programmes aimed at minimizing risk, and explored the potential impact of various biomedical interventions. MSM have developed new risk reduction strategies which models have deemed to be effective at a population level only in certain settings, such as when there are high rates of HIV testing. Modelling has also indicated that persistent circulation of drug-resistant HIV strains is likely to become an inevitable public health issue in the near future in resource-rich settings among MSM. Models have also recently been used to demonstrate that needle and syringe programmes for harm reduction among PWID are effective and cost-effective.

SUMMARY

Mathematical modelling is particularly amenable to single population groups of concentrated HIV epidemics, such as among MSM and PWID. Models have been utilized to evaluate innovative areas in clinical, biomedical and public health research that cannot be conducted in other population groups. Future directions are likely to include evaluation of specific public health programmes and providing understanding of the importance of specific treatment regimens and incidence and interaction of comorbid conditions associated with HIV.

One-year follow-up of relapse to risky behaviors and incidence of syphilis among patients enrolled in the HIV case management program

A longitudinal prospective study was conducted at an AIDS designated hospital in Taiwan. The study aimed to determine the incidence of syphilis and to identify risk factors predicting new onset syphilis and relapse into risky behaviors among 117 patients enrolled in the HIV case management program for 1 year. Having a new episode of syphilis was defined as patients had a fourfold increase of serum rapid plasma reagin titers from baseline to 12-month follow-up. After enrollment, 17% relapsed in unprotected sexual intercourse. New onset syphilis was noted in ten (10.4%) participants, and all were men having sex with men. The incidence of syphilis was 5.8 per 100 person-years. Predictors of a new episode of syphilis were higher CD4 cell counts [hazard ratio (HR), 1.003; 95% confidence interval (CI), 1.00-1.006], and recreational drug use (HR, 18.89; 95% CI, 2.78-128.15). Regular screening for syphilis among patients retaining in HIV care remains necessary.

Trends in unsafe sex and influence of viral load among patients followed since primary HIV infection, 2000-2009

BACKGROUND

In the current context of increasing unsafe sex, HIV incidence may have evolved, depending on HIV prevalence in sexual networks and, among HIV-infected persons who practice unsafe sex, on their infectivity and partners' HIV serostatus. We examined calendar trends in sexual behaviours at risk of HIV-1 transmission (SBR) among 967 adults followed since primary HIV infection (ANRS PRIMO cohort) and relationship with current treatments and viral load.

METHODS

Patients completed since 2000 self-administered questionnaires on sexual practices every 6 months. SBR with HIV-negative/unknown partners were analyzed among 155 heterosexual women, 142 heterosexual men and 670 MSM by using logistic generalized estimating equation models (6656 visits).

RESULTS

During 2000-2009, the frequency of SBR did not increase significantly among women with steady partners; risk factors were a low education level and alcohol/smoking use. Among heterosexual men with steady partners, the frequency of SBR doubled since 2006; during this period, the only associated factor was combined antiretroviral treatment for at least 6 months or viral load less than 400 copies/ml. Among MSM, SBR increased gradually over time; SBR with steady partners was associated with a low education level and alcohol use. SBR was more frequent among MSM with casual partners; no association with viral load was found.

CONCLUSION

In France, recent trends and risk factors in unprotected sex with HIV-negative/unknown partners differ according to sex/sexual preference. The recent increase in SBR among heterosexual men with low viral load may be related to increasing awareness of the 'treatment-as-prevention' concept. The lack of association between SBR and viral load among MSM supports use of treatment-as-prevention as part of diversified prevention strategies.

Prevalence and contexts of inconsistent condom use among heterosexual men and women living with HIV in India: implications for prevention

This investigation examined sexual behaviors among heterosexual persons living with HIV (PLHIV) in India. Study participants (mostly married) were interviewed during August to November 2006 in five Indian states using a quantitative survey (n = 100 men and 100 women), eight focus groups (n = 58 participants), and in-depth interviews (n = 31). One third of men and one fourth of women reported inconsistent condom use with regular sexual partners. Facilitators of condom use with regular partners included a feeling of personal responsibility to protect the health of the partner, desire to prevent acquisition and/or transmission of sexually transmitted infections, and the belief that condoms are needed for antiretroviral therapy to be effective. Barriers to consistent condom use with regular partners included the belief that condoms are unnecessary in HIV-positive seroconcordant relationships; lack of sexual satisfaction with condoms; the desire to have a child; husband's alcohol use, depression, and anxiety; fear that disclosure of HIV status will bring marital discord and family shame; and inadequate counseling by health care providers. Positive prevention programs should include counseling about benefits of safer sex in HIV-positive seroconcordant relationships, counseling about integrating condom use with sexual satisfaction and intimacy, condom use self-efficacy and negotiation skills-building, family planning counseling, mental health and alcohol dependence treatment, and counseling and skills-building about disclosure. Health care providers must be trained to provide these services. Furthermore, efforts are needed to promote tolerance for family planning choices made by couples and to counter the stigma associated with HIV/AIDS and condoms in the broader society.

Sexual behaviour, condom use and rates of sexually transmitted infections in HIV clinic attendees in South East London

The aim of this study was to examine sexual behaviour, condom use and rates of sexually transmitted infections (STIs) among attendees at a dedicated on-site STI clinic at a South London HIV centre. Data were prospectively collected by using a nurse-completed questionnaire. Ninety-eight percent of women reported one or no sexual partners in the preceding three months, whereas 57% of men who have sex with men (MSM) reported two or more partners. Only 28% of women, 53% of heterosexual men and 29% of MSM always used a condom for vaginal or anal intercourse. Positive STI diagnoses were found in 17.5% of women, 20% of heterosexual men and 49% of MSM. Twenty percent of patients who reported always using a condom and 38% of MSM reporting no sexual activity in the preceding three months had an STI. These results highlight the need for safe sex promotion and STI screening in HIV-infected patients regardless of self-reported sexual activity.

Trends in the European HIV/AIDS epidemic: a perspective from Italy

The HIV/AIDS epidemic represents one of the major public-health challenges in present days. Despite the relevant improvement in the prognosis of HIV disease following the introduction of highly active antiretroviral therapy (HAART), numerous new challenges are progressively emerging as patient characteristics evolve. In this article, we give an insight into more actual topics in the HIV/AIDS epidemic in Italy and Europe, including recent epidemiological trends, emerging drug resistance and non-B-subtype circulation, the lights and shadows of HAART and the potential of HARRT to reduce sexual transmission of HIV.

Infertility Treatment for HIV-Positive Women

Thanks to antiretroviral combination therapy, HIV-infected individuals live longer, healthier lives and may wish to have children. Women with HIV can attempt to conceive naturally or through simple self-insemination to minimize the risk of horizontal HIV transmission. Assisted reproduction technology is necessary in couples with infertility, which can either be independent of HIV infection and its treatment or be associated with it. This article summarizes the latest evidence regarding the desire for a child in HIV-positive women and how HIV infection and its treatment may impact female fertility. Current data regarding access to and outcomes of assisted conception programs in HIV-positive women wishing to conceive in both high- and low-income countries is also reviewed.

Sexual risk behaviour and knowledge of HIV status among community samples of gay men in the UK

OBJECTIVES

Undiagnosed infection presents a potential risk for the onward transmission of HIV and denies men early interventions for their health. Little is known about the differences between men who are, and are not, aware of their HIV status in the UK.

METHODS

Cross-sectional surveys of men in commercial gay venues in London, Brighton, Manchester, Glasgow, and Edinburgh (2003-2005). Anonymous, self-completion questionnaires, and oral fluid samples (tested for HIV antibodies) were obtained from 3672 men (61% response rate).

RESULTS

Of 3501 men with a confirmed positive or negative oral fluid result, 318 were HIV positive (9.1%). Of these, 131 (41.2%) were undiagnosed; 81.1% of men with undiagnosed HIV had previously tested (92.2% tested negative; the remainder did not know the result); 62.3% still thought that they were negative. Undiagnosed and diagnosed men reported greater sexual risk and sexually transmitted infections than HIV-negative men. Compared with HIV-negative men, the adjusted odds ratio of unprotected anal intercourse with two or more partners was higher among undiagnosed men (odds ratio 2.21, 95% confidence interval 1.17-4.20), but highest among diagnosed men (odds ratio 6.80, 95% confidence interval 4.39-10.52).

CONCLUSION

A high proportion of the HIV-positive men were undiagnosed and not receiving benefits of clinical care, but sexual risk and sexually transmitted infections were highest among men who were aware of their HIV-positive status. Clinics should proactively offer testing to reduce undiagnosed HIV, target repeat testing at high-risk men who have previously tested negative, and initiate evidence-based behavioural interventions to reduce sexual risk among men living with diagnosed HIV as well as those testing negative.

HIV-related discrimination reported by people living with HIV in London, UK

The objective was to examine the extent to which people living with HIV in London reported being discriminated against because of their infection. In 2004-2005, people living with HIV attending NHS outpatient HIV clinics in north east London were asked: "Have you ever been treated unfairly or differently because of your HIV status-in other words discriminated against?". Of the 1,687 people who returned a questionnaire (73% response rate), data from 1,385 respondents were included in this analysis; 448 heterosexual women and 210 heterosexual men of black African origin, 727 gay/bisexual men (621 white, 106 ethnic minority). Overall, nearly one-third of respondents (29.9%, 414/1,385) said they had been discriminated against because of their HIV infection. Of those who reported experiencing HIV-related discrimination, almost a half (49.6%, 200/403) said this had involved a health care worker including their dentist (n = 102, 25.3%) or primary care physician (n = 70, 17.4%).

Social, behavioural, and intervention research among people of Sub-Saharan African origin living with HIV in the UK and Europe: literature review and recommendations for intervention

Africans are the second largest group affected by HIV in Western Europe after men who have sex with men (MSM). This review describes and summarises the literature on social, behavioural, and intervention research among African communities affected by HIV in the UK and other European countries in order to make recommendations for future interventions. We conducted a keyword search using Embase, Medline and PsychInfo, existing reviews, 'grey literature', as well as expert working group reports. A total of 138 studies met our inclusion criteria; 31 were published in peer-reviewed journals, 107 in the grey literature. All peer-reviewed studies were observational or "descriptive," and none of them described HIV interventions with African communities. However, details of 36 interventions were obtained from the grey literature. The review explores six prominent themes in the descriptive literature: (1) HIV testing; (2) sexual lifestyles and attitudes; (3) gender; (4) use of HIV services; (5) stigma and disclosure (6) immigration status, unemployment and poverty. Although some UK and European interventions are addressing the needs of African communities affected by HIV, more resources need to be mobilised to ensure current and future interventions are targeted, sustainable, and rigorously evaluated.

Positive prevention: contemporary issues facing HIV positive people negotiating sex in the UK

Over 40,000 people are now living with diagnosed HIV in the UK. The term 'positive prevention' has been coined to describe HIV prevention that focuses on people living with an HIV diagnosis. There is uncertainty, however, about how people with HIV manage risk and how their ability to prevent the transmission of HIV is linked to their mental health and social circumstances. We analysed 44 individual and three group interviews with the people most affected by HIV in the UK: black African heterosexual men and women and gay men (mostly white). We found that participants had similar as well as contextually different needs when it came to negotiating safe sex, assimilating prevention knowledge. The themes that emerged included taking 'additional responsibility' for partners, negotiating with partners who are willing to have unprotected (anal or vaginal) sex, links with mental health, constructing the moral 'other' and power differences. We conclude with a discussion of the priorities for positive prevention for men and women living with diagnosed HIV in the UK.