HIV: Prosecution or Prevention? HIV Is Not a Crime

A chapter from the book The War on Sex edited by David M. Halperin and Trevor Hoppe. March 27, 2017 By Sean Strub

Iowan Nick Rhoades is HIV-positive and has had an undetectable viral load for many years, making it virtually impossible for him to sexually transmit the virus. When he had sex with a man he met online in 2008, he also used a condom. Despite these protective measures, Rhoades was prosecuted and convicted for not disclosing his HIV status to his partner before they had sex. He was sentenced to 25 years in prison and lifetime sex offender registration.

Willy Campbell is serving 35 years in Texas for spitting at a police officer; David Plunkett served over six years in a New York state prison before an appeals court ruled that saliva could not be considered a “deadly weapon” in New York State. Monique Howell Moree was charged by the U.S. Army for failing to disclosure her HIV-positive status to a partner in South Carolina before having sex with him, even though the partner said he didn’t want her charged and that she told him to use a condom. Kerry Thomas is serving 30 years in Idaho, even though his accuser agrees that he always used a condom.

All over the United States — and in much of the world — people living with HIV/AIDS (PLHIV) are facing criminal penalties for nondisclosure of their HIV status prior to having sex or for perceived or possible exposure to, or transmission of, HIV. About two-thirds of U.S. states have HIV-specific criminal statutes, laws that only apply to PLHIV.

Most people believe the law should apply equally to all and that creating different statutes for different parts of society based on immutable characteristics — whether it is gender, sexual orientation, race, physical ability, or genetic makeup — is a bad idea. Yet here we are doing exactly that, creating a viral underclass in the law with one group singled out for different treatment.

Sero Project, a network of PLHIV combating HIV criminalization, has documented more than 1,300 instances of charges led under HIV-specific statutes. But HIV criminalization isn’t constrained by geography; in every state, regardless of whether there is an HIV-specific statute, PLHIV can and often do face more serious charges or harsher sentencing under regular criminal statutes than do HIV-negative individuals accused of the same crimes. Texas and New York do not have HIV-specific statutes, but as mentioned, have incarcerated PLHIV because they considered their saliva dangerous.

These statutes and prosecutions create an illusion of safety for those who do not have HIV or do not know their HIV status, putting the entire burden of HIV prevention on those who have been tested and know they have HIV. The statutes undercut the fundamental public health message that HIV prevention is a shared responsibility and that everyone should act in such a way as to maintain their own health and protect themselves from contracting HIV or other sexually transmitted infections.

Decades-long sentencing and required sex offender registration are not unusual punishments for HIV-related crimes in the United States, even though actual HIV transmission is seldom (less than 5 percent of cases) a factor in these prosecutions. Many cases boil down to whether the PLHIV can prove they disclosed their status to their partners in advance of intimate physical contact; it doesn’t matter whether there was even a risk of HIV transmission. People living with HIV charged under prostitution or assault statutes frequently face significantly more severe penalties solely because they have HIV. They sometimes face charges for spitting, scratching, or biting that are “pile-on” charges, driven by accusations made by law enforcement, first responders, or prison guards.

The first HIV criminalization laws in the United States were passed in the late 1980s and early ’90s, largely in response to a provision of the Ryan White Care Act that required states, in order to qualify for funding, to demonstrate an ability to prosecute what was then labeled “intentional transmission.” At the time many considered any intimate contact with an HIV-positive person a life-threatening risk; contracting HIV was believed by many to be tantamount to a death sentence.

A second wave of statutes was enacted after the introduction of combination therapy in the mid-1990s, which fundamentally changed what an HIV-positive diagnosis meant. What was once thought a death sentence had become a chronic but manageable long-term health condition.

As it became understood that PLHIV were surviving much longer, the public’s perception of PLHIV also changed. Rather than objects of pity facing a “death sentence,” PLHIV became seen as viral vectors, potential infectors — an inherent threat to society. Living longer meant PLHIV would be around longer to infect others.

The criminal justice and public health systems began to define and treat PLHIV as a dangerous population, one that needed to be sought out, tracked down, tested, reported, listed, tagged, monitored, regulated, and, increasingly, criminalized.

While the statutes were used in the early years disproportionately often against heterosexual African American men (often in conjunction with other criminal charges), today they are used more broadly, typically in circumstances where there was no intent to harm, often when there was no other crime involved, and frequently for behaviors that pose no or little risk of HIV transmission.

Beyond the blatant injustice, HIV criminalization is also horrible public health policy, because it discourages people at risk from getting tested for HIV and makes those who do test positive less trustful of public health authorities.

To be liable for prosecution, one must get tested for HIV and know one’s HIV status. Current HIV criminalization punishes this responsible behavior — getting tested — and privileges the ignorance of not knowing one’s HIV status. Yet new cases of HIV are transmitted in disproportionate numbers by those who have not been tested and do not know they have it; those who do get tested and know they have HIV are far less likely to transmit HIV than those with HIV who do not know it.

Although the HIV-specific statutes were passed by state legislatures with the intent to reduce HIV transmission, the evidence increasingly shows that the statutes may be having the reverse effect.

The Sero Project’s 2012 survey of more than 2,000 PLHIV in the United States revealed that at least 25 percent of the respondents knew one or more individuals who were afraid to get tested for fear of facing criminalization. Research has shown that HIV criminalization makes those who do test positive for HIV less likely to cooperate with traditional disease prevention measures, like partner notification programs, or with treatment adherence programs. Most recently, a study found that HIV-negative gay men who knew they lived in a state with an HIV criminalization statute were more likely to engage in unprotected intercourse.

Repeal of HIV criminalization statutes is necessary both to protect the rights of people with HIV and to reduce the transmission of HIV.

An individual who demonstrates a premeditated malicious intent to harm another person can be prosecuted under existing assault statutes, whether they use a gun, a baseball bat, their fists, or a virus. The HIV-specific statutes are unnecessary and, worse yet, they stigmatize people with HIV/AIDS, discourage people at risk from accessing testing and treatment services, and feed a public bloodlust for punishment. In short, they are worsening the epidemic.

The prevention of HIV — or preventing any sexually transmitted infection — is a shared responsibility, but that does not mean there is not harm inflicted when someone misleads another person and transmits an infectious disease. In those circumstances, the injured party may seek recourse in the civil courts or possibly through a restorative justice process.

In any case, incarceration of PLHIV does not necessarily prevent further HIV transmission, as there is significant HIV transmission within penal environments, where condoms are seldom available.

Advocacy to repeal HIV-specific statutes, modernize public health statutes concerning perceived or possible exposure to, or transmission of, HIV and other infectious diseases, and educate law enforcement, prosecutors, and other actors in the criminal justice system has been under way for several years.

A network of survivors of HIV criminalization prosecutions, launched in 2010, has helped to educate and mobilize affected communities. This HIV criminalization reform advocacy has received support from public health professionals and policy leaders, including the Presidential Advisory Council on HIV/AIDS, the National Alliance of State and Territorial AIDS Directors, UNAIDS, and the American Medical Association.

The first national conference on HIV criminalization in the United States was held in June 2014 at Grinnell College in Grinnell, Iowa. Organized primarily by PLHIV — including participation by a dozen PLHIV who had been prosecuted for “HIV crimes” — the conference included participants from 28 states. It focused on how HIV criminalization affects communities of color, transgender women, sex workers, and gay men. It also showed the impact of HIV criminalization on how members of those communities (and others) access HIV prevention, testing, and treatment and whether they decide to disclose their HIV status. Finally, the conference highlighted effective strategies for reform.

The only state, so far, to modernize their statute substantively in recent years has been Iowa, where the conference was held. After a four-year education and lobbying effort led by Nick Rhoades and other PLHIV in the state, the Iowa legislature repealed its HIV-specific statute in 2014. The legislature replaced it with a new statute that addressed several infectious diseases, required a higher standard of intent to harm, and established tiered punishments. Similar efforts are under way in about a dozen states. A few weeks later, the Iowa Supreme Court overturned Rhoades’s conviction and removed the sex offender registration requirement for all others previously convicted under the Iowa statute.

HIV criminalization is an extreme manifestation of stigma. That is particularly true of HIV-specific statutes that create a viral underclass in the law, establishing a different criminal law for one segment of society based on an immutable characteristic. Despite the biomedical advances in the treatment of HIV, HIV-related stigma remains stubborn, driven in significant part by HIV criminalization.

It is time we learned a basic lesson: HIV can be prevented or it can be prosecuted, but not both.


Sean Strub is executive director of the Sero Project and the founder of POZ. He is the author of Body Counts: A Memoir of Politics, Sex, AIDS, and Survival.

The War on Sex contains two additional pieces on HIV criminalization: Gregory Tomso’s chapter, “HIV Monsters: Gay Men, Criminal Law, and the New Political Economy of HIV,” and Hans Tao-Ming Huang’s essay, “HIV Care as Social Rehabilitation: Medical Governance, the AIDS Surveillance Industry, and Therapeutic Citizenship in Neoliberal Taiwan.”

Straight With HIV: An Interview With Joshua Middleton

I found this article an interesting read and sometimes it is nice to share stories from a different perspective. This interview is shared from The Body and comes from amfAR, the Foundation for AIDS Research.

March 17, 2017

Joshua Middleton

Joshua Middleton (Credit: Vincent Carrella)

Joshua Middleton was 22 when he was diagnosed with HIV on June 5, 2012, during what he refers to as the prime of his life. As a non-injection drug user, non-promiscuous heterosexual, contracting HIV was the least of his worries. “After all, ‘HIV wasn’t something that happened to someone like me but to someone else,’ I told myself, right?” he says.

In 2014, 13-24-year-olds accounted for about 22% of new HIV diagnoses in the United States, according to the Centers for Disease Control and Prevention. Most occurred among young gay and bisexual males. Middleton, however, believes he contracted HIV through heterosexual sex.

In observance of National Youth HIV & AIDS Awareness Day on April 10, we spoke to Middleton, now 27, of Murrieta, Calif., about coping in the aftermath of diagnosis, combating HIV stereotypes, and raising awareness among youth.

You describe the moment you learned you had HIV like getting hit by “a ton of bricks.” What helped you cope in the immediate aftermath?

I was in a state of shock. It didn’t really hit me until a couple of minutes after the doctor told me. I had enough information on HIV to know I wasn’t going to die from it. The doctor reiterated that. I was more concerned with stigma. I thought about my life and some of the things I had been through. I had survived necrotizing fasciitis (a flesh-eating disease), septic shock, and multiple hospitalizations. I was in the ICU for three weeks. Being so close to death it really made me think to myself, “Hey, you have been through something way worse. You can get through this too.” I began by building a support network, which included joining an online support group and speaking with HIV advocates. I also educated myself. I knew a little bit about HIV, but I wanted to know everything about HIV because it was now personally affecting me.

You were also really open about your diagnosis from the beginning. What made you decide to disclose openly and honestly, especially so soon?

I think it was kind of a gunshot reaction. I didn’t really think too much. I am someone who carries my emotions on my shoulders. I was hesitant to tell my parents, but it was too big of a thing. I knew the feelings I was going through, how bad it was hitting me, and this was just the first day. I didn’t understand the exact ramifications of what it was like to live with HIV. I just knew it was pretty heavy, and I didn’t know if I was going to be able to carry that burden alone.

My goal is to raise awareness around HIV and AIDS as a young, heterosexual male, not what would be considered high risk. I want people to open their eyes and realize a small amount of risk doesn’t equal no risk.

What was the reaction from your parents? I know you also contacted your ex-girlfriend.

My parents were devastated. My mom and I cried for a couple of hours. She had a lot of questions. The first thing she asked me was, “Are you gay?” I let her know that I was not gay. She wanted to know how I got it. As for my dad, he’s more introverted, but he gave me a big hug, let me know, “Hey we’re going to get through it together.” When I told my ex-girlfriend — we had been broken up for five months — she let out a blood-wrenching scream. It was as if I had told her the whole world was ending. I said, “Look, I’m not telling you that you have it or that you gave it to me. I’m just saying I am HIV-positive, so you need to get tested.” She thought I was going to die of AIDS. She got so upset she couldn’t talk anymore and dropped her phone. Her aunt picked it up and said, “Hey I’m going to take her to get tested, don’t worry.” She was in a state of sheer terror. (Note: Joshua never heard from her after that.)

You wrote in an essay for POZ that you never thought you were at risk. How do we combat the continuing stereotype that HIV only affects certain people?

The heterosexual community needs to speak up and share their stories. I have had people in the poz community say, “You must have slept with someone who is gay. You must have slept with a girl who slept with someone who is bi.” Before I was diagnosed, the only person I had ever met who was HIV-positive was an older gay guy who spoke to my human sexuality class, and I couldn’t relate to his story. If I had a straight guy come into the room that day and say “Hey I’m living with HIV and I’m heterosexual,” it may have opened my eyes much more to say, “Hey this can happen to me.”

Why do you think a disproportionate number of new HIV infections are occurring among youth?

Youth are under the impression that they are invincible — like I was. They need to hear from someone they can relate to. They need to put faces to information. You don’t want to make HIV seem like it’s a death sentence — for the majority of the world it isn’t. But at the same time, you don’t want to promote it like it’s a basket of roses. Living with HIV has emotional, physical, and social ramifications. It’s a delicate balance. There are also problems with our sex education system. In some schools, you can’t even say the word “condom.” In fact, youth don’t have a lot of information just on the basics of HIV at least on a level they can understand. But also, parents aren’t talking to their kids about sex.

You do a lot of online activism through your blog Pozitive Hope, Facebook group, and YouTube channel. Who do you want to reach? And what do you hope to achieve?

I really want to touch people who have been diagnosed with HIV but are not yet at that level of acceptance. They are in the grieving process. Because to me that’s very critical to be able to help someone when they are in the darkest of times. My goal is to raise awareness around HIV and AIDS as a young, heterosexual male, not what would be considered high risk. I want people to open their eyes and realize a small amount of risk doesn’t equal no risk. And people really need to not get so caught up in the numbers but realize that HIV can happen to anyone.

PozQoL – a new survey valuing Quality of life among PLHIV – take part today!

Sometimes I feel like we are always committing too and getting involved in another survey but if we do not take part then how can we really get the information and data we need to help give guidance about a range of issues of relevance to us as PLHIV in 2017.

Help create a better way to understand quality of life of PLHIV. Please fill in the survey now!

www.pozqol.org.au

PozQoL is creating a better way of measuring quality of life of PLHIV.

We want to hear from PLHIV all over Australia, including people of all genders and sexualities.

PozQoL is an important study. We are testing different ways of asking about quality of life in order to improve community and health programs for PLHIV in Australia.

 You can fill in the survey online at:

www.pozqol.org.au

The survey will be online from 27 March 2017 until 15 May 2017.

The PozQoL survey is run by the Australian Research Centre in Sex, Health and Society (ARCSHS) at La Trobe University. The survey has been developed in consultation with a variety of community groups and is conducted in partnership with National Association of People with HIV Australia (NAPWHA) and ViiV Healthcare Australia. 

If you would like further information about the project, please contact the Australian Research Centre in Sex, Health and Society at La Trobe University via email (pozqol@latrobe.edu.au) or phone (+61 3 9479 8700). Please ask to speak to the main researcher on this project, Dr Graham Brown.

If you have any complaints or concerns contact the Senior Human Ethics Officer,  La Trobe University, P: 03 9479 1443, E: humanethics@latrobe.edu.au. Please quote the application reference number S17_004.

Vietnam will struggle to meet 90-90-90 targets without addressing barriers to HIV care for men who have sex with men

Another interesting article from Roger Pebody that looks at a range of barriers in Vietnam and also Swaziland to HIV care for men who have sex with men.
Roger Pebody
Published: 20 March 2017

Men who have sex with men in Vietnam risk being left behind as the country strives to achieve UNAIDS’ 90-90-90 targets for diagnosis, treatment and viral suppression, according to a qualitative study published online ahead of print in Culture, Health and Sexuality.

Health services need to make greater efforts to provide services that are acceptable and responsive to the needs of men who have sex with men, the authors say. In particular, better pre-test counselling, peer support and respect for confidentiality is needed to help men accept an HIV-positive diagnosis and engage with treatment services.

A separate study, from the very different context of Swaziland’s generalised epidemic, also highlights the need for health services to do more to help people come to terms with an HIV-positive diagnosis, if 90-90-90 targets are to be achieved.

Men who have sex with men in Vietnam

In 2014 Vietnam became the first Asian country to adopt the targets for 90% of people living with HIV to be diagnosed, 90% of people diagnosed with HIV to be on antiretroviral treatment, and 90% of people on treatment to have an undetectable viral load. As in many other countries, there are questions about whether these targets can be achieved if ‘key populations’ continue to be marginalised and discriminated against in healthcare settings.

In Vietnam HIV is concentrated in the key populations of people who inject drugs, female sex workers and men who have sex with men (MSM) – and in the sexual partners of members of these groups. HIV infections continue to rise in MSM, with 16% of MSM in the urban centres of Hanoi and Ho Chi Minh City estimated to be living with HIV.

Quantitative studies have previously shown that the uptake of HIV testing and treatment is lower in MSM than in injecting drug users or female sex workers. But little was known about MSM’s experiences accessing and engaging with HIV services and their journeys to HIV treatment.

Researchers from the Hanoi Medical University and the University of New South Wales therefore conducted in-depth, qualitative interviews with 35 HIV-positive MSM living in Hanoi. Men were recruited via community networks and snowballing techniques.

Nine of the men were not linked to care, six were linked to care but were not taking antiretroviral therapy (ART), and 20 were taking ART. Their average age was 26, half were born in a rural area, two-thirds had completed high school, and two-thirds were employed. While half identified as homosexual, almost half identified as heterosexual or bisexual. Several had married and almost half had experience of sex work.

Men were unprepared for their diagnosis

While a few participants had sought HIV testing because of an awareness of being at risk or because of symptoms, most participants had taken the test after being strongly encouraged to do so by outreach workers. Some reported not wanting to test but agreeing after being pursued by outreach workers, as this man explained:

“A guy asked me to go to an HIV testing event for the LGBT [lesbian, gay, bisexual and transgender] community. I did not want to go at first as I thought that I was not infected and didn’t want to waste time …. However, he kept contacting me and mentioning about testing again. So I did it.”

Many participants had limited knowledge of HIV before their diagnosis and had not perceived themselves to be at risk. Few participants reported receiving counselling, either before or after the test. Providers were described as being reluctant to discuss same-sex relationships or HIV risks associated with specific sexual practices.

As a result, many of the interviewees expressed shock and surprise upon receiving an HIV-positive diagnosis. Several only accepted the result after retesting several times.

“When I was informed of the HIV-positive result, I did not believe [it]. I went to Hanoi to test again but the result stayed the same. So I was very confused about how I could be infected with HIV.”

The researchers note that current policies put an emphasis on numerical targets to increase the uptake of HIV testing. Peer outreach workers receive financial incentives for the number of HIV-positive diagnoses they achieve, but less attention is given to preparing men for the possibility that their test result might be positive. Peer workers encourage MSM to test, but most settings offer no peer support after an HIV-positive diagnosis.

Many interviewees’ response to their HIV diagnosis was intense and painful.

“The result was a tremendous shock… I couldn’t think of anything and just wanted to go somewhere and do something for fun before ending my life… I did all kinds of things such as using marijuana, ecstasy and ice [crystal methamphetamine].”

“I hated him [sex partner] and other gay people also. I couldn’t trust anyone. I didn’t feel like [having sex] any more.”

These kind of reactions inhibited or delayed access to medical care.

Stigma and health system barriers

The interviews highlighted the stigmatisation of both homosexuality and HIV in Vietnam. Gay men were often seen as ‘abnormal’, families were not accepting of same sex relationships and an HIV diagnosis could compound stigma felt in relation to sexuality.

“I was so sad because, first, being a man who has sex with other men means that something is already wrong and now, being HIV infected is too much to overcome.”

The fear of stigma and discrimination made men wary of disclosing their HIV status, but engagement with medical services and daily pill-taking could make inadvertent disclosure more likely. Moreover, some participants had experienced confidentiality breaches at HIV clinics and others were nervous about the identity documents they had to provide to register with a clinic.

“After my ART initiation, the HIV clinic sent my identity information to the health station in my home town and the health station informed my mother of my HIV status… The clinic didn’t inform me that it will send my information back to my home town when asking me my identity information for registration…”

The man said he regretted testing for HIV and accessing ART. He then talked about how he felt when he spoke with his mother:

“I felt much more afraid than the moment I was diagnosed. I did not know how I can live if my family are aware of my HIV status and how my family can live in my commune if my HIV status is revealed…”

Some clinics even wanted a family member to attend with the patient before he could register there.

Participants expressed concerns about the lack of transparency and consistency in the requirements for clinic registration. They expressed concerns about eligibility criteria, having a local residency document, having to pay for services, and so on. All ART was free to patients at the time of the study, but not all participants knew this.

The interviews were conducted in late 2015, several months after Vietnam had adopted World Health Organization guidelines recommending immediate HIV treatment for MSM and other key populations, regardless of CD4 cell count (whereas individuals in the general population were only eligible for treatment if their CD4 cell count was below 500 cells/mm3).

But there was little evidence from the interviews that the policy was being applied in practice – healthcare providers did not ask men about their sexual identity, which meant they were considered ineligible for immediate treatment. In fact, some men talked about visiting several clinics or bribing clinicians in order to try to access ART.

The researchers say that their findings provided valuable insights for Vietnamese policy makers charged with scaling up ART coverage. They also believe their findings challenge the World Health Organization’s recommendation against pre-test risk assessment and counselling – they believe it would have value in this population.

Comparison with Swaziland

While some of the issues in the Vietnamese study are specific to key populations, it is notable how many of the findings echo a study on linkage to care in rural Swaziland, published in the March issue of Social Science & Medicine. In-depth interviews were conducted with HIV-positive men and women who had either engaged, or not engaged, with ART services.

Individuals who had not previously perceived themselves to be at risk of HIV had greater difficulty coming to terms with their diagnosis than others. When individuals did not feel that they had made a personal choice to test (for example, being influenced by the offer of a material incentive), this hampered acceptance of the result. Shock and disbelief at a positive diagnosis delayed linkage to care, but post-test counselling and support that offered reassurance and encouragement was crucial when provided.

“This research shows that how individuals process an HIV-positive result can fundamentally affect their engagement with health services,” the authors conclude. They suggest that testing services need to do more to explore individuals’ perceptions relating to HIV risk and the possibility of a positive result. After diagnosis, counselling over multiple sessions may be required.

“This is particularly relevant considering the 90-90-90 targets and the need to better support PLHIV to engage with HIV treatment and care following diagnosis,” they say.

Worried About HIV and Aging? The First Thing to Do Is Stop Smoking

 

At a time when we consider the impacts of aging and HIV together this article from Roger Pebody that was recently published on The Body is worth a read.

It highlights that impact that smoking has on us as we live longer with HIV and some of the implications that has on us.

January 11, 2017

The DMV Balenciaga House Meeting
Credit: sayhmog for iStock via Thinkstock

People living with HIV often worry about whether HIV is accelerating the aging process. HIV itself isn’t making many people ill, but some people with HIV are having problems with heart disease, cancers and brittle bones. These conditions — typically experienced as people get older — seem to be occurring at higher rates in people with HIV than in the general population. And they seem to be occurring at a younger age.

In trying to understand why this may be, you can find yourself delving quite deeply into some pretty technical and occasionally obscure areas of HIV science. It seems that people living with HIV may lose some degree of immune function over time, compounding deficits that typically occur in later years. Further, chronic inflammation — in other words, the immune system being in a constant state of high-alert in response to HIV infection — appears to have harmful effects on cells, tissues and processes.

For the moment, the practical implications of this emerging field of knowledge are unclear. Specific therapies to counteract chronic inflammation do not exist.

But the studies on age-related conditions and life expectancy do give some clear indications of what people living with HIV can do to improve their health as they get older.

Smoking and Life Expectancy

Let’s take, for example, a recent study that looked at death rates among clients of Kaiser Permanente. It compared almost 25,000 HIV-positive people with ten times that number of HIV-negative people.

There have been steady increases in life expectancy for people with HIV since 1996, but a troubling gap remains between their life expectancies and those of HIV- negative clients. Based on 2011 estimates, a 20-year old living with HIV could be expected to live to the age of 69, compared with an HIV-negative person living to the age of 82 — a thirteen-year difference.

But the researchers identified some people with HIV who had better prospects: People who began HIV treatment with a CD4 account above 500 could be expected to live to 74. And people who began treatment at that stage and had never smoked would live to 79.

Further exploring the impact of smoking on life expectancy, another group of researchers recently put data on the health of Americans living with HIV into a mathematical model. The researchers took as their example people who are diagnosed with HIV and start antiretroviral therapy (ART) at the age of 40.

They found that — on average — a male smoker with HIV who carried on using cigarettes would live until the age of 65. This compared with 72 years for a man who had never smoked.

A female smoker with HIV would live to 68, compared with 74 for a female non-smoker.

When looking at how a male smoker living with HIV could improve his prospects, the researchers found that quitting smoking would have the greatest impact, by adding almost six years of extra life.

Smoking and Disease

Smoking cuts people’s lives short through strokes, heart attacks and other forms of cardiovascular disease; cancers of the lung, mouth, esophagus and bladder; emphysema, bronchitis and other forms of chronic obstructive pulmonary disease — to list just a few.

Smoking could both shorten your life and have a significant impact on your quality of life. None of those health conditions are especially pleasant to live with.

That’s true for everyone, HIV positive and HIV negative. But it looks as if smoking — in some cases — may do more damage to HIV-positive than HIV-negative people. It may have a greater physiological impact on HIV-positive people.

For example, a very thorough Danish study compared the risk of heart attack in people living with HIV and people in the general population. Matching people of the same age and gender, it found that current smokers living with HIV had an almost three-fold increased risk of heart attack compared with smokers who were HIV negative. Ex-smokers living with HIV had an almost two-fold increased risk.

But people living with HIV who had never smoked had no greater risk of heart attack than matched non-smokers in the general population.

Similarly, smoking seems to have more of an impact on chronic obstructive pulmonary disease in people living with HIV than in other people.

Focus on What Can Be Changed

Rates of smoking are alarmingly high in people living with HIV. Researchers recently pooled the results of 45 different studies from North America and Europe. They found that 54% of people with HIV were smokers. That’s in contrast with just 15% of the general population of the United States.

There are people out there who are anxious about the impact HIV has on the aging process, but who continue to smoke. This is to be preoccupied by a threat that we don’t quite understand and are not sure how to deal with, while neglecting a very real health threat that can be changed and brought under control.

Physicians and community organizations need to make helping people give up smoking central to the way they take care of the health of those living with HIV. Achieving change in this area may make more difference than almost anything else they do.

And people living with HIV need to be ready to seek and accept help with getting over this addiction. It’s important to know that nicotine replacement products (such as patches and sprays) and the medications bupropion and varenicline are proven to help people quit smoking. Combining this with counseling or other support can further boost the chances of staying off tobacco in the long term.

A Centers for Disease Control and Prevention campaign features “tips from former smokers“. One former smoker is Brian, a man living with HIV who survived a stroke. He contrasts smoking with HIV, which he says will be part of his life forever: “Smoking is something that you do have control over,” he says. “You can stop. And it’s worth your life to stop smoking.”

Copyright © 2017 Remedy Health Media, LLC. All rights reserved.

 

BREASTFEEDING WITH AN UNDETECTABLE VIRAL LOAD: WHAT DO WE KNOW?

This article from Megan DePutter in the UK asks a range of questions that constantly get asked around undetectable viral load and breastfeeding.  As she says it is so important that every woman gets all the facts and then makes her own choices.

MEGAN DEPUTTER ON WHY UNDETECTABLE DOES NOT EQUAL UNTRANSMITTABLE IN THE CASE OF BREASTFEEDING, BUT WHY WOMEN SHOULD BE SUPPORTED TO MAKE AN INFORMED CHOICE ANYWAY
Breastfeeding with an undetectable viral load: what do we know?

I’m not a mother and sometimes I think that when it comes to breastfeeding I should just keep my big trap shut.

I have started and stopped this blog so many times. But I’ve decided to write it and here’s why.

I don’t think women are given enough information about breastfeeding. And I don’t think their choices are respected enough. I believe that women should be empowered to make their own choices about breastfeeding and they should be supported – not policed – in these decisions.

I also believe that women living with HIV are not often given sufficient information about the risks associated with breastfeeding. I’m seeing some voices emerge from the U=U community in support of the idea that U=U applies to breastfeeding. It doesn’t. And failing to look directly at the risks, examine them, and provide a balanced look at the issue is not supportive.

Supporting women to make informed choices on the topic does not mean eliminating information on either side of the argument. It means respecting women’s ability to understand scientific information and sharing that information willingly – instead of just telling them what not to do. And it means supporting women to make choices even when these choices may include small risks.

In this blog post I will explain why the risks are there but also why I believe that women should be supported in making a choice to breastfeed, and why I believe that more information for women is key.

Why do we hear mixed messages about HIV and breastfeeding?

Many HIV+ women I talk to about the topic of breastfeeding express confusion why the guidelines on breastfeeding vary from country to country. Women from Africa or other parts of the world will be encouraged to breastfeed despite their HIV status. From the perspective of an HIV+ woman, why should they be encouraged to breastfeed in Rwanda but not in the UK or Canada?

The answer is that in low-resource settings, where infants may be at higher risk from infant mortality caused by diarrhoea or illnesses related to parasites that may enter the body through foreign substances (unclean water or formula), breastfeeding is the best choice. When weighing the risks and benefits, breastfeeding is the safer choice.

A different approach will be taken in high resource settings where the risks and benefits are also weighed. In the UK or Canada for instance, where there is clean drinking water and formula available, it is a safer choice to simply eliminate the risk of transmission through breastfeeding. In these countries, the risk of HIV transmission outweighs any other risks. Of course, what makes sense from a public health perspective is not always what makes sense for the individual. But I’ll get back to that.

Does Undetectable = Untransmittable apply to breastfeeding?

More and more women are wondering about the role of an undetectable viral load. It seems to be pretty clear than an undetectable viral load does significantly lower the risk of transmission through breastfeeding. It lowers this risk by about 60%. This means that the risk is indeed low! But it is not zero.

When it comes to sexual transmission, we have a good body of evidence that proves that people living with HIV who have a sustained undetectable viral load do not transmit HIV to their partners, even through otherwise unprotected vaginal or anal sex. There has never been a case of sexual transmission from a person with an undetectable viral load. This is why we can unequivocally state, with sexual transmission, Undetectable = Untransmittable. There is no risk, or for the overly cautious, we could at most say there is a negligible one.

Unfortunately, we cannot say this about breastfeeding.

For one thing, there have been documented cases of transmission through breastfeeding when the mother had an undetectable viral load. Two studies showed that in 15% of cases where HIV was transmitted to infants through breastmilk, the mother was undetectable. So while PARTNER revealed zero transmissions, we simply cannot use the same terminology here given that transmissions through breastfeeding have taken place.

But why can infection occur through breastfeeding when it can’t through sex?

There are a few reasons why breastfeeding poses a risk while sexual transmission does not. One reason is that cell-associated virus is responsible for many or most infections through breastfeeding. This is a significant point as viral load testing does not measure cell-associated virus. And, because transmission takes place in an infant’s gut, there are lots of other immune cells that play a role in transmission, which would not be the case in sexual transmission.

Latently infected resting cells, HIV-infected macrophages and lymphocytes, and HIV RNA have all been found in breastmilk from women on treatment and play a role in infection. For example, macrophages and lymphocytes (white blood cells which play a role in the immune system) also facilitate the infection of CD4 cells by helping to transport HIV across the epithelial barriers.

Other reasons for increased risk include that breastmilk contains a lot of CD4 cells; infants are exposed to up to 1 million CD4 cells per day. This allows easy access to CD4 cells for infection. Inflammation caused by, for example, mastitis, breast abscesses, and engorgement, also increase the risk and other sources of infection such as cracked, blistered nipples can also provide another source of infection.

The process of infection through the infant’s gut from breastfeeding is thus quite different from that of sex, not to mention the added risk that comes from the volume of fluid that is ingested! Compared to sexual transmission, there is considerably more exposure to an infant who is guzzling breastmilk day and night for months on end, compared to even the lengthiest chem sex party!

This, and the evidence of transmission, has led researchers to conclude that ‘Indeed, the equation “no detectable HIV-1 RNA equals no transmission,” which correctly applies to sexual transmission and perinatal transmission of, does not apply to breast-feeding transmission.’ (Van de Perre, P., Rubbo, P-A., Viljoen, J., Nagot, N., Tylleskär, T., Lepage, P., Vendrell, J-P., Tuaillon, E. , 2012).

Women should be empowered to make an informed choice.

I believe it is unfair of us to incorrectly state that U=U when it comes to breastfeeding. We are giving women misinformation by doing that. We are not supporting them in understanding the scientific information so that they – for themselves – can weigh the risks and benefits.

Mothers do not have it easy. They face a tonne of pressure and criticism from outside voices, be they scientific, medical, social, cultural, or familial. The same applies to many facets of motherhood, including breastfeeding.

The message that ‘breast is best’ is so heavy handed that it makes it difficult to for mothers to feel anything other than a terrible mother for failing to give their child ‘the best’. Pressures can come both internally and externally – there are cultural expectations, norms and beliefs; emotional and physiological desire, information on the internet, feelings of loss, grief, and guilt, the desire to bond with the baby, the opinions of friends and family, pressure from health and social care organisations, the social construction of motherhood and identity, concern for the baby’s health… and good old HIV stigma. Stigma, both external and internal. Stigma, that can, particularly for women in high prevalence communities, lead to gossip or even inadvertent disclosure of HIV status – which comes with a genuine threat to health and wellbeing.

Still, lots of women will choose to sacrifice everything for their baby, and upon knowing the risks, may choose not to breastfeed.

This is part of making an informed choice, however. It should be up to the woman to weigh the risks and benefits – but that necessitates a proper explanation of the risks and why they exist.

Women with HIV who are considering breastfeeding should be given scientific information about how transmission occurs and the role of the immune system – not just cursory information. I believe that everyone has the capacity to understand scientific information about HIV transmission if it is presented in a clear and thoughtful manner. But how often do we have opportunities to communicate with health practitioners about this?

More often than not, we are simply told not to do something. We are not told how, or why, a risk is present. Only that it’s there.

Supported to breastfeed despite the risks

Here in the UK, women with HIV in the UK are advised not breastfeed their babies even with an undetectable viral load. The British HIV Association (BHIVA) and Children’s HIV Association (CHIVA) Position Statement on Infant Feeding in the UK (2010) states:

‘To prevent the transmission of HIV infection during the postpartum period, BHIVA/CHIVA continue to recommend the complete avoidance of breastfeeding for infants born to HIV-infected mothers, regardless of maternal disease status, viral load or treatment.’

However, in the UK, breastfeeding is not an automatic child protection issue and mothers who breastfeed will still receive support. In Canada, (which also has harsher criminalisation laws), a more hard-line approach is used. I think that the British model is much better.

Even with all of the risks I have described, I still think that women should be able to make the choice to breastfeed.

Why?

1.  While it’s clear that being undetectable does not eliminate the risk of infection as it does in sexual or vertical transmission, it significantly reduces the risk. The risk is low enough that, in my opinion, women should have the option to take this risk.

2.  Women should have the right to make the best decisions about the health of their children. We should have the ability to weigh the risks and benefits and decide for ourselves what is the best decision given the context of our lives. But this means that we should be given more, not less information. I think that HIV+ women should be given more information on the topic – including why the guidelines are different by country, the rates of transmission, and how infection occurs.

3.  Public health decisions are made from a population health perspective, not an individual one. In this case, guidelines are set because the absolute safest thing to do is not to breastfeed. If no mothers living with HIV will breastfeed, we eliminate that risk altogether. If we take our goal of eliminating HIV transmission, this does make sense. But many times this translates to advice that just does not suit the context of our individual lives. As Harvey Pekar wrote, ‘ordinary life is pretty complex stuff.’ For many reasons, we simply cannot always make the safest, or the most optimal choice that is given under advisement of our doctors.

4. In situations where women feel that abstaining from breastfeeding is not possible or simply not the right choice, it’s far better to support women to reduce the risks, such as by providing strategies that can help to lower risk (such as medication adherence, exclusive breastfeeding, avoiding breastfeeding if there is an infection or cracked, blistered nipples, etc.)

Writing this piece may alienate me from either side of the argument. But I am concerned that women may not necessarily have the information nor the support from the medical communities on this subject, nor from wider health and social care or even from HIV/AIDS organisations. The HIV community has an important role to play in listening, training, supporting and advocating on this issue.

Works consulted:

Breastfeeding and HIV International Transmission Study Group, Coutsoudis A, Dabis F, Fawzi W, Gaillard P, Haverkamp G, Harris DR, Jackson JB, Leroy V, Meda N, Msellati P, Newell ML, Nsuati R, Read JS, Wiktor S. Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis. J Infect Dis. 2004 Jun 15;189(12):2154-66. Epub 2004 May 26.

British HIV Association (BHIVA) and Children’s HIV Association (CHIVA) Position Statement on Infant Feeding in the UK (2010)

Canadian Paediatric Society (2017). Testing for HIV infection in pregnancy.

Coovadia HM1, Rollins NC, Bland RM, Little K, Coutsoudis A, Bennish ML, Newell ML. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet. 2007 Mar 31;369(9567):1107-16.

Government of Canada (2015). Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months. A joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada

Gordon, B. Breastfeeding wars: is breast really best? To breastfeed or not to breastfeed? If you feed your baby formula rather than mother’s milk, you’ve probably already felt the disapproval of the ‘Breastapo’. But is breast really always best? The Telegraph 1:20PM BST 20 Aug 2014.

HIV iBase (2015), Guide to HIV, Pregnancy & Women’s Health.

Kennedy, L., Serghides, L., Greene, S. Webinar: A Complicated Dilemma: HIV and infant feeding (2014). www.catie.ca/en/webinar-series-positive-parenting

Khosla, P., Ion, A., & Greene, S. (2016). Supporting Mothers in Ways that Work: A Resource Toolkit for Service Providers Working with Mothers Living with HIV. Hamilton, ON: The HIV Mothering Study Team.

Manigart O1, Crepin M, Leroy V, Meda N, Valea D, Janoff EN, Rouet F, Dequae-Merchadoux L, Dabis F, Rouzioux C, Van de Perre P; Diminution de la Transmission Mere-Enfant Study Group. Effect of perinatal zidovudine prophylaxis on the evolution of cell-free HIV-1 RNA in breast milk and on postnatal transmission. J Infect Dis. 2004 Oct 15;190(8):1422-8. Epub 2004 Sep 9.

O. Manigart, M. Crepin, V. Leroy, N. Meda, D. Valea, E. N. Janoff, F. Rouet, L. Dequae Merchadoux, F. Dabis, C. Rouzioux, P. Van de Perre; Diminution de la Transmission Mere-Enfant Study Group, Effect of perinatal zidovudine prophylaxis on the evolution of cell-free HIV-1 RNA in breast milk and on postnatal transmission. J. Infect. Dis. 190,1422–1428 (2004).

Overbaugh, J., and Milligan, C. (2014, December 14). The Role of Cell-Associated Virus in Mother-to-Child HIV Transmission. Journal of Infectious Diseases. 210 (suppl 3).

Public Health England (2015). HIV in the UK – Situation Report 2015.

Royal College of Midwives. (2014). Infant Feeding: Supporting Parent Choice.

Royal College of Nursing. (2016). Formula feeds: RCN guidance for nurses caring for infants and mothers.

UNICEF UK (2012). Guide to the Baby Friendly Initiative Standards.

Van de Perre, P., Rubbo, P-A., Viljoen, J., Nagot, N., Tylleskär, T., Lepage, P., Vendrell, J-P., Tuaillon, E. (2012). HIV-1 Reservoirs in Breast Milk and Challenges to Elimination of Breast-Feeding Transmission of HIV. Science Translational Medicine. 118 July Vo 4, Iss.143.

World Health Organization. (2016). Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV.

World Health Organization. HIV/AIDS: Mother-to-child transmission of HIV.  

Social Isolation Is Dangerous for Your Health: Here Are Some Solutions

March 10, 2017

birds on wires
Credit: OgnjenO via iStock

I found this article on The Body and thought the points that David makes are really important to consider.  Social isolation occurs for many and we need to look at how we can change, support and work together to reduce this and to build resilience in our community.

 
Most of us living with HIV/AIDS know intuitively that social isolation, something we all have experienced, is emotionally painful. There is now a growing body of evidence that it can also be deadly. A recent article in Heart noted that people living with HIV have a 50% greater risk for myocardial infarction (MI) than HIV-negative persons, as well as a greater risk for stroke. When combined with the known effects of social isolation on health outcomes (for example, persons who lack social support are 1.5 times more likely to have an MI), it becomes clear that individuals, health care providers and communities need to quickly address the problem of social isolation.

“Social isolation” is defined as a lack of contact and social support between an individual and other people. It differs from loneliness, which is a subjective experience that is often more temporary. Isolation shouldn’t be confused with the number of people around an individual. A person living with HIV can be surrounded by crowds of people, yet because of stigma and discrimination, experience low self-worth or carry secrets that result in the very same subjective experience of social isolation. Even a perception of social disconnectedness has a negative impact on mental health, especially anxiety and depression.

The origins of social isolation among people living with HIV are not difficult to discern. HIV-related stigma results in economic, social and legal marginalization, as well as shame, discrimination (or fear of discrimination), low self-worth and trauma, all of which can lead to social withdrawal. Physical factors play a role, as well. HIV/AIDS can cause fatigue resulting in fewer social outings, neuropathy can reduce mobility and physical manifestations such as lipodystrophy can result in avoidance of social relationships, sex, work and sport activities.

The effects of social isolation are profound. In addition to an increase in cardiovascular risk noted above, a lack of connectedness can impact quality of life in many areas. For example, sleep can be disrupted, the immune system can become even more compromised because of increased stress hormones and mental health problems such as depression and anxiety can become more common. One study found that 8.2% of HIV-related deaths were the result of suicide, and social isolation is almost certainly a contributing factor. Even medication adherence can be adversely affected by social disconnectedness resulting from internalized stigma and low self-esteem. To make matters worse, many people turn to addictive behaviors such as opiates, stimulants and high-risk sex to find relief from the emotional pain of social isolation.

No one living with HIV/AIDS is immune from the impact of isolation. Numerous studies find that social isolation is a problem among the aging population in general, and especially among the elderly living with HIV. Younger persons are also affected. One study found that younger people living with HIV/AIDS experience more disconnectedness from family and friends than their older peers do. Researchers believe this is due to a combination of factors, including stigma, feeling blamed by others for their illness and younger people not identifying with the need to battle a chronic illness. It should also be noted that persons affected by HIV/AIDS, especially those who went through the 1980s and 1990s, can experience the same symptoms of trauma and isolation as people who are HIV-positive.

Social isolation is clearly a risk to emotional and physical health. Here are some steps you can take to protect yourself and increase your quality of life.

Be Proactive

Don’t wait for someone to reach out to you. Get up and out, knowing that you are not alone. Many other persons share similar feelings of shame, fear of discrimination and low self-worth. Find them in your community. Your presence will be a healing force for them and you. If physical mobility is a concern, remember that old-fashioned telephone calls are welcome, and look into what solutions can be provided by technology with forums and chatrooms (such as those at TheBody.com or POZ).

Identify Your Specific Needs

People living with HIV need various types of support depending on their current circumstances, so it is important to get clear on what your needs are at any given time. During periods of high stress, anxiety or depression, emotional support is the most helpful. At other times, one might need tangible support such as help getting groceries or walking the dog. Finally, if there is a change in your health, it might be necessary to get informational support. What are the facts about a health problem, and what are your options? When seeking medical information, it’s important to rely on carefully vetted sites such as TheBody.com to be certain that what you are reading is accurate.

Find a Buddy

In the early days of the epidemic when there were no systemic supports for people living with HIV, buddy systems developed that were enormously helpful. They involve checking in physically or by phone (now text, as well). A buddy might go to the doctor with you, help with a chore or just be a friendly listener on a difficult day. The highly evolved HIV bureaucracy of medical and social service programs plays an important role today, but sometimes being able to pick up the phone and speak with a friend is far easier and more soothing than reaching a case manager.

Practice Stress Management

Taking care of ourselves, including addressing pervasive feelings of shame, fear and low self-worth, is the foundation of healthy social connections. We need to believe that we deserve a high quality of life, and we must utilize tools to combat the stress resulting from feelings or beliefs that undermine us. Many stress-reduction techniques are free and simple, including deep breathing, progressive relaxation, walking in nature or playing with your dog or cat (or any other creature that gives you unconditional love). Avoiding a build-up of stress has great implications for keeping us healthy.

We need other people for our emotional and physical survival. HIV/AIDS can undermine these connections in any number of ways, but there are solutions, and they must begin with us. Reach out and get connected. We are waiting for you.

David Fawcett, Ph.D., L.C.S.W., is a substance abuse expert, certified sex therapist and clinical hypnotherapist in private practice in Ft. Lauderdale, Florida. He is the author of Lust, Men, and Meth: A Gay Man’s Guide to Sex and Recovery.

Australia has been invited to participate in a global survey of the needs of PLHIV and we are nearly halfway to target!

We have until the end of the month to recruit another 75 Australian participants.

 The study has been commissioned by an independent, global specialist HIV company with commitment to deliver innovative new options for the care and treatment of people living with HIV/AIDS. They have partnered with an independent market research agency in order to execute the survey.

The aims of the survey are to:

  • Gather insights around key issues and remaining needs as perceived by PLHIV and their partners/significant others. This includes recognising that certain key affected populations, including women and PLHIV over the age of 50, have distinct needs in terms of their treatment and care that need to be better understood.
  • Communicate the findings to raise awareness of the ongoing issues and needs (this may include the sharing of findings at major scientific conferences, publication to community media outlets and provision of relevant information to patient advocacy groups, etc). Note also that key study findings will be available to the public in 2017 via a dedicated portal for the initiative, via the commissioning company’s website.
  • Use the insights gathered to inform and shape future activities that provide meaningful support for PLHIV.
  • Track the key trends and shifts in the needs of PLHIV over time.

The link below allows interested participants to register their interest (once completed they would be contacted by someone from the survey company).

www.liberatingsurveys.com/en/enquire/3/orgchg

Please help us reach the target and circulate this email through your networks and connections.

The New M.A.C VIVA Glam Ambassadors are here – Empire’s Taraji P Henson and Jussie Smollett!

Taraji P. Henson and Jussie Smollett Go From “Empire” to MAC Viva Glam [VIDEOS]
The cosmetics line has raised over $450 million for AIDS causes since 1994.
Ariana recently did it. So did Miley, Gaga and Cyndi. Even Ricky Martin and k.d. lang have puckered up for MAC Cosmetics to raise money for AIDS causes. And now we meet the new faces of the Viva Glam campaign: Taraji P. Henson and Jussie Smollett, stars of the hit TV show Empire.
Created in 1994, the MAC AIDS Fund has raised over $450 million by selling its unique lipstick and lipglass specifically to help men, women and children across the globe affected by HIV/AIDS. For her moment in the MAC spotlight, Henson created a matte fuchsia with pearl lipstick and matching shimmery lipglass, each available for $17 with 100 percent of the proceeds going to the cause.
“One lipstick literally provides one rapid oral HIV test, 14 HIV tests for pregnant mothers, [or] 254 condoms to prevent HIV infection,” explains Smollett in a Teen Vogue profile on the Empire duo’s AIDS advocacy.
Watch the campaign’s cute commercial and an interview below—we love the ’90s “Shoop” vibe—and visit MAC here to order the cosmetics.
For more about the history of the Viva Glam campaign, including a glamazon gallery, visit macaidsfund.org.


HIV Positive Smokers Who Quit Cut Their Risk of Numerous Cancers

However, unlike HIV-negative quitters, their lung disease risk remains highly elevated for at least five years after kicking the habit.

If people living with HIV who smoke quit their cigarette habit, they soon cut their risk of numerous cancers, aidsmap reports. However, unlike HIV-negative people who quit smoking, HIV-positive ex-smokers maintain a much higher, non-declining risk of lung disease for at least five years to follow.

Researchers from the D:A:D cohort analyzed data on all the HIV-positive participants’ cancer incidence between 2004 and 2015. They compared the cancer rates between those who currently smoked, never smoked, who had quit cigarettes before entering the study and who quit during the study.

Findings were presented at the 2017 Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle.

A total of 35,424 participants, 46 percent of whom were smokers and 20 percent of whom were ex-smokers, were diagnosed with 1,980 cancers between them, including 242 lung cancers, 487 other cancers considered related to smoking and 1,251 other cancers not considered related to smoking.

The notable proportions of cancers occurring in each of the four groups of participants were as follows: lung cancer, 70 percent among current smokers and 21 percent among ex-smokers; other smoking-related cancers, including head and neck, esophageal, stomach, pancreatic, kidney and urinary, ovarian and liver cancer, 52 percent among smokers and 21 percent among ex-smokers; cancers not related to smoking, 47 percent among smokers and 20 percent among ex-smokers.

The researchers found that for about the first year or so after quitting cigarettes, the participants’ risk of smoking-related cancers, save for lung cancer, fell dramatically and after that hit a level comparable to that of nonsmoking people with HIV. This drop in risk was unaffected by participants’ age, CD4 count or sex.

With regard to lung cancer, after the researchers adjusted the data for various factors, they found that the risk remained 8.26-fold higher for ex-smokers for as long as five years after they quit cigarettes compared with HIV-positive never smokers. HIV-negative smokers, on the other hand, start to realize a decline in risk of lung cancer within five years of quitting.

National Day of Women Living with HIV – promoting awareness

As we move to celebrate International Women’s Day we are also proud to be supporting the National Day of Women Living with HIV…please see the press release from NAPWHA and Femfatales…

The following points that Katherine Leane makes are important  and raise some valid points for us all to consider on this important day.

National Day of Women Living with HIV — promoting awareness

Celebrate. Advocate. Inspire. Empower.
March 9 will be the second National Day of Women Living with HIV. Coming the day after International Women’s Day, this awareness-raising day was created by Femfatales, a network of women living with HIV of the National Association of People with HIV Australia (NAPWHA).

“We are aiming to create a greater awareness of the needs of women living with HIV in Australia, “said Femfatales Chair, Katherine Leane. “It’s hard to believe that in 2017 some people don’t think that there are women living with HIV in this country. But there are around 3, 000 of us, or about 10 percent of the HIV-positive population.

“Because of the perception that women are not at risk of HIV, women don’t test for it. Many women who are diagnosed with HIV here have never tested for it previously, not believing they were at risk. This can present them with serious health challenges as a late diagnosis can mean that they have developed a compromised immune system and sometimes, an AIDS-defining illness.

“On top of this, many suburban and regional GPs have never diagnosed someone with HIV, do not always recognise the symptoms or risk factors and are not sure where to refer patients for specialist care. It is very important that women diagnosed in these settings get referred to appropriate medical care and to the peer support agencies that can help people with their diagnoses.

“The more people talk about HIV, the more we encourage women to test for it, the more we will be able to diagnose and treat women appropriately. This is the aim of this special day,” said Kath.

“We encourage all agencies involved with and concerned about women’s sexual health to hold a morning or afternoon tea or other event to help raise awareness of HIV agencies that support women living with and affected by HIV.”

For more details contact:

Femfatales Convenor, Katherine Leane
0410 707 923

NAPWHA Executive Director, Aaron Cogle
0468 438 214

NAPWHA is Australia’s peak non-government organisation representing community-based groups of people living with HIV. NAPWHA provides advocacy, policy, representation, health promotion and outreach at a national level.

When We Rise – a must see!

SBS Miniseries “When We Rise” Features AIDS Activism [VIDEO]

Real-life heroes inspired this chronicle of LGBT history. The first episode airs Saturday March 11 at 8.30pm on SBS.  All too often we get asked about the history of the LGBT movement and its affect on our lives as we attempt to move forward and linked to this is HIV/AIDS history and the affect that the epidemic has played on many aspects of the story.
An epic retelling of the LGBT civil rights movement in the US , spanning four decades and based on real-life pioneers, the SBS miniseries When We Rise  of course includes HIV/AIDS as a prominent part of that history.

The four-part series is written by Dustin Lance Black, who won an Academy Award for his Milk screenplay, about assassinated gay rights leader Harvey Milk. According to SBS press materials, Gus Van Sant, who directed 2008’s Milk, helmed the first episode of When We Rise.

Starring Guy Pearce, Mary-Louise Parker, Rachel Griffiths, Michael Kenneth Williams and with guest appearances such as Whoopi Goldberg, T.R. Knight, Debra Winger, David Hyde Pierce and Phylicia Rashad, the miniseries centers on the stories inspired by real-life LGBT leaders, including Cleve Jones (played by Austin P. McKenzie and, later, Guy Pearce), who created what became the AIDS Memorial Quilt. Jones, along with transgender activist Cecilia Chung (played by Ivory Aquino, who is transgender and was recently profiled in the US People magazine) and several other people in the story are HIV positive.

“There have been so many points in my life when I thought I was done and the movement was done, and I want people to be aware of that right now with Trump,” Jones told The Daily Beast in an extensive interview. “When it seems like it may be over, it’s never over.” In talking about the AIDS crisis, he adds that in San Francisco’s Castro area, “the total death toll in this neighborhood was 25,000—half the gay men of my generation. Half died, half of us survived, and many of those who did survive are still here. That’s a lot of personal tragedy.”

Guy Pearce plays AIDS activist Cleve Jones in “When We Rise.”ABC/Eike Schroter

The battle against HIV/AIDS is portrayed in the miniseries alongside other social justice causes such as same-sex marriage equality.

Parts of When We Rise are based on Jones’s recent memoir of the same title.

Ivory Aquino plays transgender activist Cecilia Chung in “When We Rise.”ABC/Eike Schroter

Michael Kenneth Williams plays community organizer Ken Jones in “When We Rise.”ABC/Eike Schroter

Breast Feeding and HIV – another interesting and relevant paper from CROI

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.  This post comes directly from the ASHM website and this is is an important issue that still can be and is surrounded by controversies, depending on where in the world you are, so I thought it important to share this with you.

Greetings from Seattle, the Emerald City, Washington.

It’s 8pm on 11/2/17 (or 2/11/17 depending on your preference) and it’s currently a brisk 48oF (9oC) compared to 44oC at home yesterday.

My initial impression on arriving in Seattle was the apparent anti-Trump sentiment in the Pacific North-West evident from the graffiti on the wall on the way from the airport announcing “STOP TRUMP”, to the Washington state legal action against the travel ban, which is currently underway.

Day 1: Today I attended the 7th International Workshop on HIV and Women, a small workshop with a select audience of 120 registrants, 10% being men. The major focus of this meeting is to present the latest data on HIV as it affects women and most importantly to promote a dialogue and interaction between participants.

Session 1 focussed on current controversies in breastfeeding – related basic science, clinical trial evidence was presented and the session concluded with a debate on the pros and cons of breastfeeding in the context of HIV.

Infant feeding is a complex issue and related choices by an HIV infected mother should always support prevention of HIV transmission, provide greatest nutritional benefit and prevent the infant experiencing significant non-HIV morbidity and mortality eg from diarrhoeal diseases.

There are many factors which can influence transmission of HIV via breast milk which I will not elaborate here.  Note that some studies have shown that mothers with undetectable HIV RNA in the blood can still transmit HIV in breast milk because antiretroviral drugs do not pass into breast milk with full, equal efficacy.  Studies indicate passage of NNRTIs into breast milk of 80%, PIs 20%, and there is no passage of Integrase Inhibitors (in the one paper to date).  Further sub-optimal drug levels of ARVs in breast milk may contribute to drug resistance in the infant. There is also a different viral load in breast milk between each breast. Recent trials (Mma Bana and PROMISE Study) indicated risk of MTCT from breast milk was 0.3% in the context of ARV treatment. However, we do not know what may be the best ARV regimen for breast feeding mothers.

It is very important to be aware of the latest WHO Guidelines which were updated on 01/08/2016. I draw your attention to these new guidelines as they do now have more relevance to developed world settings.  The WHO Guidelines have usually been intended for countries with high HIV prevalence, and there is not wide adoption of the WHO Guidelines in highly developed countries, and of course there are longstanding regional guidelines in operation – eg US Guidelines (last updated October 2016) where breast feeding is not recommended (AII), with guidelines from other regions – BHIVA/CHIVA, Australia, Canada (CAPG and SOGC) being similar.

In a number of developed world settings, women are starting to breast feed in the context of full virological suppression and infant post exposure ARVs (including triple therapy!) and there are some emerging case reports on outcome. In many instances women are breast feeding without their health providers knowing.

Canada is now developing a national policy document relating to the follow-up of women who have breast fed their infants.  Further, be aware that Switzerland is now starting to allow breast feeding for women with an undetectable HIV viral load and the identified cohort will be followed prospectively.

It is increasingly apparent that there is a now an emerging dilemma as to whether we can start to recommend breast feeding by mothers with HIV infection in all settings.  Are we reaching a point now in our clinical practices, where there is sufficient safety data to consider supporting breast feeding?  A recent survey of health care providers suggests that nearly 50% of health care providers would consider offering a breast-feeding option regardless of speciality.  This is in the context of a background prevailing attitude of health providers which is, quite understandably, zero tolerance for any infant HIV acquisition. There was also acknowledgement that there is an evolving professional tension in some settings, between Paediatric ID clinicians and maternal HIV clinicians and a tendency for there to be “policing of mothers” in the community and by some health providers.

The outcome of the debate on these issues in this session, was that it is time for there to be a more open discussion between women living with HIV, in a “shared care” arrangement with their health provider, on the risks and benefits of breast feeding.  This discussion must also emphasise maintaining adherence and full virological suppression, as studies have shown a decline in adherence in the post-partum period.  The session also concluded that there needs to be a relevant dialogue between health care providers and the development of governmental or professional organisational guidelines to assist health care providers in offering a breast feeding option.

New York’s strategy to end the HIV epidemic – an interesting perspective

 

 

 

 

 

 

At the recent Conference on Retroviruses and Opportunistic Infections 2017 (CROI) held in Seattle Washington in March there was a range of interesting and informative presentations on different aspects of treatment, living with HIV, ending HIV and a range of other research findings.

The following is a report from a presentation on the New York Strategy to move towards and end to HIV there. I think the idea of a ‘status neutral’ approach is one that needs further discussion…don’t you?

New York City’s strategy to end the HIV epidemic is firmly rooted in science, was developed in conjunction with community activists, and has support from top-level political leaders, Demetre Daskalakis told CROI 2017.

“When you combine political will, biological interventions and harm reduction, you can get to zero,” he said.

Dr Daskalakis is an unusual public health figure: an infectious disease physician who has delivered testing and vaccination in sex clubs and describes himself as a “queer health warrior”. He is now the deputy commissioner for disease control in the New York City Department of Health and is the architect of the city’s “ending the epidemic” initiative.

New York’s strategy places particular emphasis on identifying people with undiagnosed HIV and linking them to healthcare; retaining people in care to maximise virus suppression; and facilitating access to pre-exposure prophylaxis (PrEP). Mayor Bill de Blasio and Governor Andrew Cuomo have given political and budgetary support to the initiative, facilitating implementation by a range of government agencies.

The city’s sexually transmitted disease clinics are being transformed into ‘destination clinics’ that will provide efficient gateways that will link people to post-exposure prophylaxis (PEP), PrEP and HIV treatment. Same-day initiation for all these services is now offered, with social workers and benefits navigators dealing with insurance problems and underlying social issues. Contraception, HPV (human papillomavirus) vaccination, cervical and anal screening are all also offered.

The city has adopted what it calls an ‘HIV status neutral’ prevention and treatment cycle that places HIV testing at the beginning. People living with HIV need to be prescribed antiretroviral therapy and retained in high-quality care, which is understood to be an ongoing process. The other half of the cycle pictures engagement with prevention for those who test HIV negative and are at risk of HIV. The individual remains engaged with high-quality sexual health services in an ongoing manner, which is understood to facilitate awareness and use of PrEP.

A ‘status neutral’ approach treats people taking HIV treatment and people taking PrEP in the same way, in the same services, thus reducing stigma, Daskalakis said.