This article is reprinted from www.aidsmap.com by Michael Carter and was published on 18 February 2019
HIV-positive smokers metabolise nicotine at a significantly higher rate than HIV-negative individuals, investigators from the United States report in the online edition of AIDS. The finding could explain why people with HIV have more difficulty quitting smoking than their HIV-negative peers. A second study involving the same HIV-positive smokers and published in the Journal of Acquired Immune Deficiency Syndromes showed that a higher nicotine metabolism ratio (NMR) was associated with symptoms of anxiety and treatment with efavirenz.
The researchers say their findings have important implications for the use of smoking cessation medication by individuals with HIV, and that more intensive therapy with varenicline (Chantix and Champix, an oral prescription medication), rather than nicotine replacement patches, is warranted.
“The mean NMR of this sample resembles levels reported among those with opioid dependence,” comment the authors. “Although the nature of the relationship between NMR and HIV is uncertain, these results suggest that the nicotine patch would have limited therapeutic benefit for most smokers with HIV, which has been reported, and that varenicline would be more beneficial.”
People with HIV are more likely to smoke and have more difficulty quitting than individuals in the general population. Smoking-related diseases are now a leading cause of serious illness and death among people with HIV and supporting smoking cessation should be part of routine HIV care.
The rate at which the body metabolises nicotine could explain why people with HIV are more likely to become smokers and find it harder to stop. Nicotine is metabolised by the body using the CYP2A6 liver enzyme. Research has shown that people with reduced CYP2A6 function (slow nicotine metabolisers) smoke fewer cigarettes, are less dependent on nicotine and are more likely to succeed in quitting smoking. NMR is a widely used measure of CYP2A6 function.
Investigators from the University of Pittsburgh hypothesised that smoking behaviours in people with HIV were influenced by NMR. They therefore designed an observational study comparing NMR between 131 HIV-positive smokers and 199 closely matched HIV-negative smokers.
Data were collected on factors known to impact on NMR, including sex, race, gender and body mass index (BMI).
Most of the participants were male (70-74%), African American (72-79%) and were living on an annual income below $35,000.
Almost all the HIV-positive participants were taking antiretroviral therapy (ART). Eighty per cent had an undetectable viral load and the average CD4 cell count was 714 cells/mm3.
The individuals with HIV smoked significantly fewer cigarettes daily than the matched population (13 vs 15, p = 0.003). Despite this, mean NMR was significantly higher in the people with HIV than the HIV-negative individuals (0.47 vs 0.39, p < 0.001).
Participants were divided into four groups according to NMR speed: people living with HIV were twice as likely as HIV-negative individuals to be placed in the fourth quartile, the fastest metabolisers (35% vs 17%).
“These findings suggest that HIV-infected smokers metabolize nicotine faster than HIV-uninfected smokers, even after controlling for relevant demographic and behavioral factors,” write the authors. “Understanding the mechanisms that contribute to faster nicotine metabolism among PLWH [people living with HIV] is necessary to understand tobacco’s role in undermining clinical outcomes in HIV, and identifying novel therapeutic interventions.”
The second study examined whether there were any specific characteristics associated with a higher NMR in the 131 HIV-positive people.
The investigators collected demographic data, information on CD4 cell count and viral load, CD4 cell count, ART type and adherence and symptoms of anxiety and depression. Breath carbon monoxide was also evaluated.
The initial analysis showed that race, symptoms of anxiety and depression, greater smoking intensity, breath carbon monoxide and therapy with efavirenz were all associated with higher NMR values.
After taking into account known potential confounders, a higher NMR remained associated with smoking more cigarettes per day (p = 0.050), higher levels of symptoms of anxiety (p = 0.054), and therapy with efavirenz (p = 0.003). Treatment with efavirenz accounted for 5% of the variance in NMR.
“Taking efavirenz was associated with higher NMR, rather than lower NMR as expected for a drug interaction (efavirenz would be predicted to inhibit CYP2A6), which needs to be understood further,” comment the authors. “This suggests that efavirenz therapy should be considered when addressing tobacco use among PLWH.”
Ashare RL et al. Differences in the rate of nicotine metabolism among smokers with and without HIV. AIDS, online edition, DOI: 10.1097/QAD.0000000000002127, 2019
Schnoll RA et al. Rate of nicotine metabolism and tobacco use among persons with HIV: implications for treatment and research. J Acquir Immune Defic Syndr, 80: e36-40, 2019.
This article comes from Al Jazeera and highlights the plight that people in Yemen have to deal with daily.
Most Yemenis living with HIV/AIDS face stigma and discrimination, even from their own families.by Naseh Shaker & Faisal Edroos22 Jan 2019
The patients names have been changed to protect their identity.
Sanaa, Yemen – With each breath, the red rashes on Ahmad’s cheeks appeared to get brighter and brighter.
The eight-year-old had just made his way up the stairs of the al-Jumhurriya hospital in the Yemeni capital Sanaa, one of the few health centres in the war-ravaged country that still provides free medical treatment to people living with HIV.
As he took his seat in the waiting room next to his ailing father, the sound of static from an old analogue TV appeared to startle the tired young boy, further heightening his anxiety as he waited for doctors to call him in for his latest blood test.
Three years ago, Ahmad was healthy and playful, his father Zakariyya told Al Jazeera.
“When he became sick, we took him to the hospital where doctors carried out tests and told us he had problems with his immune system,” he said.
“They later told us it was HIV.
“My wife and I also took the tests and we also tested positive.”
An acronym for the human immunodeficiency virus, HIV attacks important cells that help the body fight off infections, disease, and other viruses.
When the infection goes untreated, it causes AIDS. This typically causes fever, weight loss, recurrent diarrhoeal infections and other symptoms.
While both are seen as treatable, a cure has yet to be found.
‘I take a red pill every day’
Zakariyya said his family moved to Sanaa sometime in 2016 for treatment when fighting engulfed his neighbourhood in the southwestern city of Taiz.
As Houthi fighters were being expelled from the city, air attacks and street clashes devastated Taiz, forcing at least 37 of its 40 hospitals and medical institutions to close.
According to local authorities, Doctors without Borders, best known by its French initials MSF, was one of the few aid agencies that continued providing free antiretroviral (ARV) treatment to the 600 people living with HIV/AIDS in the capital.
The situation was so dire, that some of the patients began rationing their medicines because of the difficulty associated with reaching clinics and hospitals.
Citing the case of one woman, MSF said that she began taking half a tablet instead of a whole one and even began taking them on alternate days so she didn’t have to completely stop her treatment.
Zakariyya said he and his family were among the fortunate ones and received their intended doses.
“The doctors have given us medicine,” he said. “I don’t know its name, but it’s a red pill. I take one every day.”
The government has zero funds allocated for HIV and AIDS
TAHA AL-MUTAWAKEL, MINISTER FOR HEALTH IN THE HOUTHI-RUN ADMINISTRATION
Thrown out of their homes
According to the World Health Organization, the first HIV case appeared in Yemen in 1987, and the number of people living with it was estimated to be around 9,900.
While prevalence was only 0.2 percent of the population, most Yemenis living with either of the viruses faced stigma and discrimination, even from their families.
According to the most recent report by Stigma Index, the world’s largest social research project implemented by people living with HIV, most HIV-positive Yemenis had been thrown out of their homes by family members due to fears of infection.READ MORE
The research said that all the people they interviewed experienced some form of stigma because of their HIV status, with one third saying they had to “change their residence or could not rent a place” because of their condition.
Ibrahim al-Babli, a doctor at the HIV/AIDS laboratory at the al-Jumhurriya hospital, said those patients were not the only forgotten victims of this war.
A staggering 1.2 million civil servants living in Houthi-held areas had not received their salaries after the Yemeni government stopped paying them in late 2017 in an effort to start a popular uprising.
The effects were devastating, with health, education and sanitation services left without the people needed to run them.
Resources were stretched so thin, Babli said, that patients were lucky to enter a manned hospital.
“I haven’t received my salary in months, I get paid sporadically,” said Babli.
“If doctors aren’t cared for, then that means there’s no care for the patients.”
‘Zero funds for HIV/AIDS’
The United Nations has repeatedly described Yemen’s humanitarian situation as “catastrophic” and, on Wednesday, Mark Lowcock, the under-secretary-general for Humanitarian Affairs, said the situation had worsened in the past year with “more than 24 million people now needing humanitarian assistance”.
Taha al-Mutawakel, the minister of health in the Houthi-run administration, told Al Jazeera that the war had crippled the health system with “zero funds allocated for HIV and AIDS”.
“We’re currently operating with a grant of $800,000 provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria,” he said.
“Medicines are readily available and offered free of charge and distributed to each of the governorates … but the siege has had a major impact on patients seeking treatment.”
Saudi Arabia, which has been conducting an air campaign in Yemen since March 2015, intensified its embargo on the country in 2017, restricting both humanitarian aid and commercial goods from entering Houthi-held ports.
The kingdom said the blockade was a necessary precaution aimed at preventing weapons from being smuggled into Yemen by Saudi Arabia’s regional rival, Iran.
The inadequacy of services … may increase the vulnerability to HIV/AIDS transmissions
ELTAYEB ELAMIN, REGIONAL PROGRAMME ADVISER AT UNAIDS MIDDLE EAST
‘Race against time’
Eltayeb Elamin, the Regional Programme adviser at UNAIDS Middle East said the situation in the country had greatly affected the movement of HIV and AIDS patients, with the “disruption to the supply system … leading to difficulties in the accessibility for available services”.
“The effect of the war on the health infrastructure is also greatly stressed with inadequate supplies hampering HIV/AIDS prevention efforts especially counselling and testing,” he said.
“The inadequacy of services … may increase the vulnerability to HIV/AIDS transmissions through lack of universal precautions and inadequacy of needed services.”READ MORE
Zakariyya said while he was still in the dark about his son’s future, he was confident that with some treatment, he could go on to live a full life.
“My son nearly died. But now, all praise to God, he is doing much better,” he said. “We believe in God and have faith that our lives and our fate are in his, not our, hands.”
Meritxell Relano, UNICEF’s resident representative in Yemen, said that with the fighting showing no signs of abating, aid agencies were in a “race against time” to save children such as Ahmad.
“We urge for an end to the war on children, not tomorrow, but today,” she said. “Parties to the conflict must work to reach a negotiated political solution, prioritising and upholding the rights of the children.
“The longer this war continues, the more children are going to die on the world’s watch.”
Resources are stretched so thin, that according to Dr Babli, patients are lucky to enter a manned hospital [Al Jazeera]
Poz.com explores an issue that needs more research but at present is pointing to this being real for many.
More high-quality evidence is needed to determine how this class of HIV medications may affect weight gain.
The integrase inhibitor class of antiretroviral (ARV) medications may be associated with weight gain, aidsmap reports. A review of observational studies and clinical trials found the risk to be pronounced among women and Black people.
Publishing their findings in the Journal of Virus Education, researchers looked for studies that could provide information about weight changes after starting one of the four approved integrase inhibitors: Isentress (raltegravir); Tivicay (dolutegravir), which is included in Triumeq (dolutegravir/abacavir/lamivudine) and Juluca (dolutegravir/rilpivirine); Vitekta (elvitegravir), which is included in Stribild (elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate) and Odefsey (emtricitabine/rilpivirine/tenofovir alafenamide); and bictegravir, which is not approved as a stand-alone pill and is included in Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide).
The study authors reviewed a handful of randomized clinical trials—in which differences in ARV regimens were the result of randomization—including:
The ACTG 5257 study, in which those who received Isentress, in particular Black participants, were more likely to become overweight or obese compared with those who received boosted Prezista (darunavir) or Reyataz (atazanavir). All participants took Truvada (tenofovir disoproxil fumarate/emtricitabine) as a backbone to their ARV regimen.
The NEAT-001 study, in which all participants took Isentress and those who took it with boosted Prezista developed higher trunk fat levels after 96 weeks compared with those who took Isentress plus Truvada.
The SPRING-1 study, in which weight gain was greater among those who took Tivicay compared with those who took Sustiva (efavirenz).
The Gilead 1490 study, in which participants took either Tivicay or bictegravir. Both groups gained 3 kilograms (6.61 pounds) over 96 weeks. All study members took Descovy (emtricitabine/tenofovir alafenamide) as a backbone.
Some research has suggested that the tenofovir alafenamide component of Descovy is associated with weight gain compared with the older version of tenofovir, the tenofovir disoproxil fumarate component of Truvada.
As for observational studies, which are a less robust source of scientific evidence than randomized trials, findings included:
Tivicay plus Ziagen (abacavir) was associated with greater weight gain than Tivicay plus Viread (tenofovir disoproxil fumarate). It is not clear whether this indicates that Viread moderates any weight gain linked to integrase inhibitors.
Several observational cohort studies saw greater weight gain in those starting or switching to an integrase inhibitor, particularly women.
More research is needed to determine whether integrase inhibitors are associated with weight gain and whether any such gain in body fat is associated with various negative health outcomes. Obesity is associated with diabetes, cardiovascular disease (CVD) and cancer in particular, all of which occur at higher rates among people with HIV compared with the general population.
Researchers analyzed 10 biomarkers associated with biological aging among a group of HIV-positive and -negative Europeans.
This article is a reprint from POZ.com from January 17, 2019 •By Benjamin Ryan
People living with well-treated HIV may experience faster biological aging than their HIV-negative counterparts.
Publishing their findings in the journal AIDS, researchers from the ComorBidity in Relation to AIDS (COBRA) study analyzed 134 people with HIV and 79 HIV-negative people with similar sociodemographic and lifestyle factors. The participants were recruited in Amsterdam (these were at least 45 years old) and London (these were at least 50 years old).
All the HIV-positive individuals were on antiretrovirals and had had a fully suppressed viral load for at least 12 months.
The researchers also studied samples from 35 blood donors selected from the Dutch national blood bank in Amsterdam. They were matched with the HIV-positive and -negative individuals from the COBRA study according to age and had all tested negative for HIV, hepatitis B and C viruses (HBV/HCV), syphilis and human T-lymphotropic virus 1 and 2 (HTLV).
The investigators tested the participants for 10 biomarkers that previous research has indicated are associated with biological, as opposed to chronological, aging.
Among the COBRA study members, biological age was greater than chronological age by an average of 13.2 years among those with HIV and 5.5 years among those without the virus. For the blood donors, biological age was an average of 7.0 years lower than chronological age.
After adjusting the data for various factors, including HIV status, the study authors found that the following factors were significantly associated with a greater average biological age compared with chronological age: chronic HBV, 10.05 years; total anti-cytomegalovirus (CMV) IgG antibody levels, 1.83 years per 10-fold increase; and CD8 cell count, 0.44 years per 100-cell increase.
After adjusting for chronic HBV infection status, total anti-CMV IgG antibody levels and CD8 levels, the analysis indicated that the HIV-positive COBRA participants had a greater discrepancy between biological and chronological age compared with their HIV-negative counterparts (4.5 years on average) and with the blood donors (19.0 years on average).
After conducting another analysis in which they adjusted the data for various factors, the study authors found that HIV-related factors associated with a greater biological age compared with chronological age included: cumulative exposure to the antiretroviral Invirase (saquinavir), 1.17 years per year of exposure; a lowest-ever (nadir) CD4 count of less than 300, 3.0 years; chronic HBV, 7.35 years; and total anti-CMV IgG antibody level, 1.86 years per 10-fold increase.
This important article comes from Devex.com and puts the International AIDS Conference into perspective.
AMSTERDAM — The fight to end HIV/AIDS was given a boost by a star-studded week of presentations, panel sessions and the occasional protest at this year’s International AIDS Conference in Amsterdam. However, tensions within the community remain, and with few new funding pledges announced, there are questions about how to translate strong rhetoric into action.
Some 16,000 stakeholders from more than 160 countries gathered in the Dutch capital last week for AIDS 2018, the conference’s 22nd edition and one of the biggest events in the global health calendar, featuring sessions on the latest HIV science, policy, and practice.
Held under the theme of “Breaking Barriers, Building Bridges,” the real story of this year’s conference was the growing realization that the HIV/AIDS epidemic is in crisis, with 1.8 million new infections in 2017. There are also alarming spikes in new HIV cases among key groups including adolescent girls in sub-Saharan Africa and drug users in eastern Europe and parts of Asia, according to recent figures from UNAIDS. At the same time, development assistance for HIV dropped $3 billion between 2012 and 2017, according to a study by the Institute for Health Metrics and Evaluation.
“The feel is definitely less congratulatory than past conferences and more sobering,” Rachel Baggaley, coordinator for HIV prevention and testing at WHO, told Devex, but added that it was good to see the community responding with force. The activist spirit which has defined the fight against AIDS in the past was never far away, she noted, with many sessions interrupted by campaigners.
“It is very positive to see the AIDS movement hasn’t gone away … I went feeling rather down and have come away challenged and inspired; there’s a lot of things we must do and a lot of people who continue to take this [AIDS agenda] forward,” she said.
The key now will be turning the strong rhetoric and passion seen throughout AIDS 2018 into action on the ground, according to youth HIV activist Mercy Ngulube.
“We are all going to build bridges this week … but where is your bridge going to lead us? Don’t let your bridge be a bridge to nowhere,” she said during the opening plenary.
Key messages from the week were:
1. Target key populations
Attendees agreed that, without drastic change, the world will see global HIV targets missed and a possible resurgence of the epidemic. But Peter Piot, founding executive director of UNAIDS and now director of the London School of Hygiene and Tropical Medicine, warned the targets themselves could leave key populations even further behind.
Speaking on Thursday, Piot reminded the audience that the 90-90-90 targets set by UNAIDS in 2014 will miss 27 percent of HIV patients. The framework calls for countries to get 90 percent of people living with HIV diagnosed; 90 percent of those diagnosed to be accessing treatment; and 90 percent of people on treatment to have suppressed viral loads by 2020.
“The 90-90-90 targets are actually 90-81-73,” he said, adding that “what the future of the epidemic is going to be determined by is the 10-10-10” — those not hit by the targets.
The 10-10-10 is likely to be made up of key populations including sex workers, men who have sex with men, LGBTI groups, people who inject drugs, and young people — all of whom are less likely to access HIV services due to social stigma, discrimination, criminalization, and other barriers, Piot said. These groups currently account for 47 percent of people with new infections, according to UNAIDS data.
Reaching these key populations was high on the agenda last week. Dudu Dlamini, a campaigner for sex workers’ health and rights who was awarded the Prudence Mabele prize for HIV activism during the conference, spoke to Devex about the need to decriminalize sex work in order to remove barriers to HIV services for sex workers.
Leading HIV scientists also put out a statement in the Journal of the International AIDS Society about laws that criminalize people with HIV for not disclosing their status and for exposing or transmitting the disease. Such laws, which exist in 68 countries, “have not always been guided by the best available scientific and medical evidence,” it said, and when used inappropriately can reinforce stigma and undermine efforts to fight the disease.
2. Prevention pay off
With new infections standing at 1.8 million last year, the recent UNAIDS report describes a “prevention crisis.” Traditionally, prevention has received only a tiny proportion of HIV funding, with the bulk going toward treatment. But there was a new buzz around the prevention agenda at this year’s event, in part driven by excitement around oral pre-exposure prophylaxis, or PrEP, which can prevent HIV infection among those at high risk. The antiretroviral medication has been successfully rolled out in North America, western Europe, and Australia, and has been shown to help reduce new infections among men who have sex with men.
“There is a prevention crisis and we need to find better ways of addressing it,” said Christine Stegling, executive director of the International HIV/AIDS Alliance. But while PrEP is a promising tool, a full approach to prevention needs to include a range of methods, combined with interventions that tackle human rights issues and gender inequality, she said.
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3. A youth bulge
It was impossible to miss the strong youth presence at this year’s AIDS conference, which organizers said had a larger number of young people attending than ever before, and featured dozens of youth-focused events. This is linked to a growing recognition that adolescents face a disproportionately high risk of becoming infected with HIV, especially in Africa where the population is set to rapidly increase, and where new infection rates are on the rise among young people.
Ugandan youth advocate Brian Ahimbisibwe, a volunteer ambassador for the Elizabeth Glaser Pediatric AIDS Foundation, said: “Without the youth, the future of all these conferences, and more importantly [of] services and programs, [is] compromised.”
However, 28-year-old Tikhala Itaye, co-founder of women’s rights group Her Liberty in Malawi, said the youth voice had not been fully integrated and that young people were still being “talked at” during many of the sessions, as opposed to being listened to.
“There’s now acceptance that young people need to be at the center … they do have the demographic weight and power to influence issues around HIV,” she said, but “you still find the different youth events happening in different rooms … Why aren’t we all coming together as one to build the bridges and have a global voice?”
4. The need for integration
A number of sessions talked about the need to integrate HIV programming, which has traditionally been siloed due to having its own funding streams, into broader health care. This was a key message of The Lancet Commission report on strengthening the HIV response published ahead of the conference, and was also the message delivered by WHO director-general Tedros Adhanom Ghebreyesus during the opening plenary.
“We have not truly helped a child if we treat her for HIV, but do not vaccinate her against measles. We have not truly helped a gay man if we give him PrEP but leave his depression untreated … Universal health coverage means ensuring all people have access to all the services they need, for all diseases and conditions,” he said.
Baggaley said integrating HIV into the broader health agenda posed both “an opportunity and also a challenge and risk for those populations most marginalized,” explaining that key populations currently served by externally funded nonstate health services could see their assistance diminished under UHC if the country in question did not believe UHC includes key populations or had punitive laws against gay men or sex workers, for example.
There was much discussion around the need to combine HIV and tuberculosis efforts, especially in the run up to the first U.N. high-level TB event in September. TB is the number one killer of people with HIV, who are up to 50 times more likely to develop it, according to WHO.
Speaking in between interruptions from the crowd, former U.S. President Clinton highlighted the need to address HIV and TB in tandem during the closing plenary and called on world leaders, notably India which has the highest TB burden, to attend the upcoming U.N. TB meeting.
“If you think … anyone ..that we can possibly bring the developing world to where we want it to be by abandoning the fight against HIV/AIDS and the collateral struggle against TB, you need to think again,” he said.
New findings from the Sustainable East Africa Research in Community Health program, presented during the conference, showed positive results from a community-based program which combined HIV testing and treatment with other diseases including TB, diabetes, and hypertension. The findings of a three-year randomized controlled trial in Kenya and Uganda showed that communities receiving testing and care for HIV alongside related conditions saw nearly 60 percent fewer new TB cases among HIV-infected people and that hypertension control improved by 26 percent.
5. Medical developments
Concerns about GlaxoSmithKline’s so-called “wonder drug” dolutegravir, which a study recently suggested might be linked to serious birth defects among children in Botswana, sparked debate amongst conference goers about whether potential mothers should be prescribed the drug.
WHO already advises that women of childbearing age wishing to take the antiretroviral have access to effective contraception, and will be re-evaluating its guidance as new evidence emerges, Baggaley told Devex. But there are concerns the agency could introduce blanket restrictions for women of childbearing age, which would force them to take other antiretroviral drugs that have worse side effects. The controversy could also lead to delays in the rollout of other forms of the drug, such as a pediatric version.
The conference also featured new data from the APPROACH study, which is evaluating the safety of several different HIV vaccines currently undergoing clinical trials in the U.S., East Africa, South Africa, and Thailand — but researchers admitted a vaccine will take years to develop.
6. The Trump effect
The shadow of U.S. President Donald Trump’s beefed-up “global gag rule,” otherwise known as the Mexico City Policy, loomed large over the conference, and a number of sessions discussed how it is negatively affecting HIV programs. Unlike previous iterations of the policy — which restricts U.S. funding to non-U.S. organizations that offer services related to abortion — Trump’s version is applied to almost all U.S. global health assistance, including PEPFAR.
Santos Simione from AMODEFA, an NGO that offers sexual health and HIV services in Mozambique, said his organization had lost U.S. funding due to the gag rule and was forced to close half of its youth clinics, which offered sexual and reproductive health services alongside HIV testing, counseling, and antiretroviral therapy.
“We could not provide condoms … testing … we just stopped everything,” Simione said.
Participants also spoke of a chilling effect, whereby organizations have stopped offering services that may not actually be prohibited under the rule, and raised concerns about PEPFAR’s staying power within a hostile Trump administration.
Meanwhile, there was heated debate about arrangements for the next conference, which the International AIDS Society has said will take place in San Francisco, California, in 2020. The decision has been met with fierce opposition and threats to boycott the event from AIDS campaigners who say many key population groups affected by HIV will have difficulties attending due to strict immigration policies. In 2009, former U.S. President Barack Obama lifted a restriction banning people with HIV from entering the country, but sex workers and people who use drugs still face legal challenges entering.
While rates of new HIV cases are falling in Australia, there’s been a sharp increase in diagnoses among Asian-born gay men.
By Rosemary Bolger from SBS News
An alarming trend in the rise of HIV among Asian gay men has prompted health and support services to call for expanded access to HIV-prevention drugs and more education programs targeting specific ethnicities.
Jimmy Chen had never been to a gay club until he moved to Australia from Taiwan three years ago.
But a short-term relationship with a man changed his life last year.
After undergoing a routine three-monthly sexual health status check, the 24-year-old was diagnosed with HIV.
“At the beginning, I just felt empty and also I feel like I don’t have any emotion going on in my mind,” he told SBS News.
While far fewer Australian-born men are being diagnosed with HIV, new diagnoses for gay men born in Southeast Asia, living in Australia, rose sharply between 2014 and 2016.
There was also an increase among Northeast Asian-born men.
Data from New South Wales shows the alarming trend is continuing.
There were 29 per cent more new cases among overseas-born gay men in the first quarter of this year, compared to the previous five years.
At the same time, the number of Australian-born gay men newly diagnosed fell 63 per cent.
CEO of the AIDS Council of New South Wales (ACON), Nicolas Parkhill, says criminalisation of homosexuality in migrants’ home countries, such as Indonesia, could be in part to blame.
“You’re going to have a very different perspective I think about accessing health care, particularly to get a HIV test or talk about sexual health for fear of privacy, for fear of some sort of reprimand,”
The HIV-prevention drug PREP is now cheaply available for most Australians, but uptake of the game-changing medication is lower among Asian gay men.
CEO of the AIDS Council of New South Wales (ACON), Nicolas Parkhill.
Mr Parkhill says that’s because a lot of international students or people on working holidays do not have access to Medicare.
“We’re really keen to work with certainly all governments on what might be an access scheme for people who we certainly know are high risk, certainly know can’t afford or can’t get access to things like PREP or treatment for people we know so that coverage is really, really targeted.”
The organisation is also trialling an education program targeting Chinese gay men.
Tim Chen explains the program is conducted in Mandarin.
“It has a Chinese name ‘Tong shi yao ling yao’, it’s a six-week-long structured workshop and each week has a different topic, like coming out, identity, sexual health, relationships, and getting involved in the communities in the last session.”
It’s one of a range of programs targeting Asian gay men with the aim of increasing the use of prevention strategies, such as condoms and PREP.
ACON hopes to adapt the program to target other Asian ethnicities.
Those that have already contracted HIV could become a key part of the strategy.
Jimmy Chen used to worry about how others would react to his diagnosis.
“At the beginning, I felt what if I tell them my HIV status they might turn away from me. What if I tell my partner, they won’t accept me anymore. And what if just being a stranger next to me and you know I’m HIV positive you might feel uncomfortable… that’s why I feel scared.
But he’s no longer afraid.
“This is a just a thing, a virus living in my body. But it doesn’t change my personality, I’m still who I am.”
Australian HIV-negative gay men express far more confidence in pre-exposure prophylaxis (PrEP) than an undetectable viral load in preventing HIV, with only 18% agreeing that “a person with an undetectable viral load cannot pass on HIV” and 6% feeling comfortable having condomless sex with an HIV-positive partner who had an undetectable viral load, according to a pair of articles recently published in Sexually Transmitted Infections and AIDS & Behavior.
Confidence in the efficacy of PrEP was much higher.
Researchers from the Burnet Institute conducted an online survey with gay and bisexual men living in Melbourne and other parts of the state of Victoria. It included a series of questions to gauge men’s knowledge of and attitudes towards condoms, an undetectable viral load and PrEP.
Australia has a long history of promoting condom use and regular HIV testing in gay men. More recently, there has also been high-profile support for treatment as prevention and PrEP. Around the time the survey was conducted in August and September 2016, a PrEP demonstration project was scaling up in Victoria. Several Australian campaigns promoting the benefits of HIV treatment had already been run, but the international “Undetectable = Untransmittable” campaign had not yet taken off.
Half the survey participants were between the ages of 25 and 40; most identified as gay; and 20% were born outside Australia. A third reported condomless sex with a casual partner in the past six months, and half with a regular partner.
The survey was completed by 844 people, but men with diagnosed HIV were excluded from the following analyses. The data on comfort having condomless sex come from 771 HIV-negative or untested men, including 83 PrEP users (12% of the men). The data on perceptions of effectiveness come from a smaller group of 462 survey respondents who answered all relevant questions and were not using PrEP. (The researchers did not report on responses from PrEP users for these questions.)
Perceptions of effectiveness
Although this analysis excluded current PrEP users, the majority of respondents expressed confidence in PrEP’s effectiveness: 78% agreed that “PrEP is effective in preventing HIV infection” and 65% agreed that “An HIV-negative person who is on PrEP is unlikely to get HIV”. Respondents also agreed that PrEP users were “being responsible” (74%) and were “protecting themselves” (84%).
In contrast, 18% agreed that “A person with an undetectable viral load cannot pass on HIV”. A similar statement, with less definitive language was not much more popular – 20% agreed that “An HIV-positive person on treatment is unlikely to transmit the virus”.
Despite this scepticism, other findings showed that respondents were aware that HIV treatment has a prevention impact – 37% agreed that “If more HIV-positive men have an undetectable viral load, then I’m less likely to get HIV” and 82% agreed that “HIV-positive people should go on treatment to protect their partners”.
Moreover, taking treatment soon after diagnosis appears to have become a community norm – 84% agreed that “People should start treatment as soon as they are diagnosed”, while statements suggesting that people should delay until they are completely ready or until treatment is absolutely necessary were supported by fewer than 10%.
This cohort of HIV-negative men generally rejected relying on their partners using antiretrovirals in order to be protected from HIV. They suggested that their personal sexual strategies would not change in response – 16% agreed that “If more men are on PrEP, I would feel like I don’t need to use condoms to avoid getting HIV”. Similarly, 12% agreed that “Because of PrEP and HIV treatments, I’m less likely to ask my partners about their HIV status”.
Comfort having condomless sex
Men were asked, “How comfortable would you be having anal sex without a condom with casual partners in the following scenarios?” and were asked to respond for a number of partner types. There were important differences between the responses of PrEP users and non-users.
The 668 men who were not taking PrEP were generally uncomfortable with the idea of having condomless sex – only 7% said they would be comfortable doing so with ‘any casual partner’, 5% with a casual partner of unknown HIV status and 3% with an casual partner who was HIV positive.
It made little difference if the HIV-positive partner had an undetectable viral load – 6% would feel comfortable having sex with him.
Men appeared to be more comfortable serosorting, although this can be a risky strategy for HIV-negative men as there is always the possibility that a partner has recently acquired HIV but has not yet been diagnosed. Among men not using PrEP, 31% said they would be comfortable having condomless sex with a casual partner described as HIV negative. If the same man was taking PrEP, fewer men (23%) would be comfortable having condomless sex with him, perhaps reflecting a perception of PrEP users as risk takers.
The 83 respondents who were using PrEP were more comfortable with the idea of having condomless sex, but comfort levels were not particularly high.
PrEP users were most likely to feel comfortable having condomless sex with other HIV-negative PrEP users (72%) and HIV-negative partners not taking PrEP (64%).
The proportion who would feel comfortable having condomless sex with an HIV-positive partner (29%) was lower than for a partner of unknown HIV status (34%) or ‘any casual partner’ (40%).
And less than half of current PrEP users would be comfortable having condomless sex with an HIV-positive partner with an undetectable viral load (48%), although the respondent would be protected by two extremely effective prevention methods.
“While gay and bisexual men are highly supportive of pre-exposure prophylaxis, there remains some scepticism towards HIV treatment when used for prevention,” sum up the authors. “Increasing community understanding of treatment as prevention is needed to optimise treatment-based HIV prevention strategies.”
“In general, HIV-negative and untested gay and bisexual men indicated that they remained more comfortable negotiating condomless sex based on knowledge of HIV status, rather than PrEP or undetectable viral load.”
Many men continue to rely on serosorting: “HIV-negative men tend to perceive all sex with HIV-positive partners as potentially risky, regardless of condom use, HIV treatment or viral load.”
Some commentators have suggested that PrEP and understanding of undetectable viral loads could help reduce HIV stigma and the fear of partners living with HIV. However, PrEP users’ relatively high levels of discomfort with the idea of condomless sex with HIV-positive partners suggest that these hopes may be over-stated, the authors comment.
By Roger Pebody
Wilkinson AL et al. Measuring and understanding the attitudes of Australian gay and bisexual men towards biomedical HIV prevention using cross-sectional data and factor analyses. Sexually Transmitted Infections 94: 309-314, 2018. (Abstract.)
Holt M et al. Comfort Relying on HIV Pre-exposure Prophylaxis and Treatment as Prevention for Condomless Sex: Results of an Online Survey of Australian Gay and Bisexual Men. AIDS & Behavior, online ahead of print, 2018. (Abstract.)
Declining rates are expected for Kaposi sarcoma, non–Hodgkin lymphoma, cervical and lung cancer and Hodgkin lymphoma, among others.
This story is taken from a recent article by Benjamin Ryan on Poz.com
May 8, 2018 •
By 2030, the most common cancers among people with HIV are projected to be prostate and lung cancer.
Publishing their findings in the Annals of Internal Medicine, researchers analyzed data from the National Cancer Institute’s HIV/AIDS Cancer Match study, modeling cancer diagnosis rates during 2000 to 2012 to make projections about how rates will change from 2013 to 2030.
The U.S. HIV population is steadily aging, thanks to effective antiretroviral treatment. In 2006, an estimated 27 percent of the population was age 50 or older, a proportion that increased to 45 percent in 2014. Between 2010 and 2030, the proportion of the population age 65 and older is expected to increase from 8.5 percent to 21.4 percent, while the proportion that is age 45 to 64 is expected to increase from 39.4 percent to 47.7 percent.
Between 2000 and 2012, the 463,300 HIV-positive adults in the HIV/AIDS Cancer Match Study were diagnosed with 23,907 cancers. During this period, the annual diagnosis rates (known as incidence) declined for Kaposi sarcoma (KS), non–Hodgkin lymphoma (NHL), cervical cancer, anal cancer (among men who have sex with men), lung cancer, Hodgkin lymphoma and other cancers among all age types. Colon cancer incidence decreased among those age 65 and older. Meanwhile, prostate cancer incidence increased among men ages 35 to 64.
Overall, cancer incidence among the U.S. HIV population is expected to decline through the next decade.
Among three AIDS-defining cancers, the estimated numbers of diagnoses seen in the U.S. HIV population in 2010 and projected to occur in 2020 and 2030, respectively, according to the study authors’ analysis were: 8,150, 7,490 and 6,690 diagnoses of NHL; 1,490, 750 and 450 diagnoses of KS; and 120, 50 and 30 diagnoses of cervical cancer.
As for non-AIDS-defining cancers, the respective numbers of diagnoses seen in 2010 and projected to occur in 2020 and 2030 were: 5,420, 6,150 and 5,980 diagnoses of lung cancer; 830, 910 and 1,030 diagnoses of prostate cancer; 750, 1,340, 1,590 diagnoses of anal cancer; 360, 460 and 480 diagnoses of liver cancer; 300, 200 and 120 diagnoses of Hodgkin lymphoma; 250, 320 and 340 diagnoses of oral cavity/pharyngeal cancer; 220, 260 and 260 diagnoses of breast cancer; 220, 230 and 200 diagnoses of colon cancer; and 1,910, 1,880 and 1,510 diagnoses of other types of cancers.
The study authors concluded that their findings stress the importance of expanding access to HIV treatment and cancer prevention, screening and treatment.
This is according to the world’s first study to conduct an analysis of PrEP’s apparent effect on the HIV rate on a public-health level.
March 14, 2018 •By Benjamin Ryan reposted from Poz.com
After a rapid scale-up of the distribution of Truvada (tenofovir disoproxil fumarate/emtricitabine) as pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in New South Wales, the diagnosis rate of recently contracted HIV among MSM dropped by 32 percent in the Australian state, which includes Sydney.
This dramatic shift occurred after the province’s HIV diagnosis rate had held essentially steady during the preceding years. The recent period researchers factored into their analysis saw only relatively modest increases in the HIV population’s viral suppression rate. So treatment as prevention is not likely the primary driver of the considerable change in the HIV rate. (If HIV is fully suppressed with antiretroviral (ARV) treatment it effectively cannot transmit.)
“Really, the main thing that changed by far during this period was PrEP,” said Andrew Grulich, PhD, an HIV epidemiologist at the Kirby Institute at the University of New South Wales in Sydney, who presented findings from the study at the 2018 Conference on Retroviruses and Opportunistic Infections (CROI) in Boston.
Andrew Grulich speaks at CROI 2018 in Boston.Benjamin Ryan
Seeking to conduct the world’s first analysis of PrEP’s wide-scale effect on a population’s HIV rate, researchers secured funding from the New South Wales Ministry of Health to start 3,700 people on PrEP beginning in March 2016. The target population included adults who were at a high and ongoing risk for HIV according to local guidelines. Those who had compromised kidney function (an eGFR test result below 60) were excluded.
Those receiving PrEP were scheduled to receive a baseline-screening visit, a one-month follow-up visit and screening visits every three months thereafter.
Demand for PrEP proved considerable: 3,700 people started PrEP within eight months of the study’s launch. Consequently, the investigators behind the study were able to convince the local government to give them greater financial backing; by the end of 12 months, 7,621 individuals had received PrEP.
Of the first 3,700 people, 8 percent were 18 to 24 years old, 36.7 percent were 25 to 34 years old, 29.3 percent were 35 to 44 years old and 26 percent were 45 years old or older. A total of 99.4 percent of the overall group was male, 95.5 percent identified as gay and 4 percent identified as bisexual. A total of 47.1 percent received PrEP from a public sexual health clinic, 48.6 percent from a private general practice and 4.4 percent from a hospital.
Eighty percent of new HIV cases are among MSM in New South Wales, so PrEP was well positioned to make a major dent in the state’s HIV rate given its rapid uptake among this population.
A total of 3,602 people (97.4 percent) received at least one follow-up HIV test during the study. This population was included in one of the key parts of the final analysis.
The study authors looked at a so-called medication possession ratio over 12 months among the individuals receiving PrEP, specifically the estimated percentage of a year’s supply of Truvada that individuals obtained during their first year after initially receiving the drug. The median possession ratio was 97.8 percent, meaning that more than half of those receiving Truvada received almost an entire year’s worth. Seventy percent of the study population received 80 percent of a 12-month supply of the drug, while 14 percent received 50 to 79 percent, 13 percent received 10 to 49 percent and 3 percent received less than 10 percent of a year’s supply within 12 months of first receiving PrEP.
During a cumulative 3,927 years of follow-up among those 3,602 people, two of them tested positive for HIV. One individual was given PrEP but never started it, and the other took no Truvada for months before contracting the virus.
Consequently, the researchers concluded that the study population contracted HIV at the very low rate of five cases per 100,000 cumulative years of life.
The investigators looked at the HIV rate among MSM in New South Wales according to state surveillance from March 2015 through February 2016, the 12-month period before the study began recruiting people, and compared that rate to the one seen during the 12-month period after the study enrolled its first 3,700 people, November 2016 through October 2017.
By the end of this time, the study had recruited 7,621 to start on PrEP.
During the initial 12-month period and the latter 12-month period, MSM in New South Wales saw a respective 149 and 102 diagnoses of HIV that were deemed to be infections MSM had contracted within 12 months. These two periods saw a respective 295 and 211 total HIV diagnoses among MSM, including both recent and more long-term infections. That meant that among MSM in this province, diagnoses of recent HIV infections dropped by 32 percent and all HIV diagnoses fell by 25 percent.
Breaking down the decline in the rate of recent infections among MSM in New South Wales by age, the investigators found that those 18 to 24 years old saw a 9.5 percent decline (21 cases before, 19 after), those 25 to 34 years old saw a 22 percent decline (58 cases before, 45 after), those 35 to 44 years old saw a 44 percent decline (39 cases before, 22 after) and those 45 years old and older saw a 48 percent decline (31 cases before, 16 after).
While the decline in the recent infection rate among those born in Australia or another high-income, English-speaking country dropped by a respective 49 percent (78 cases before, 40 after) and 33 percent (12 cases before, 8 after), the rate for those born in Asia dropped only 21 percent (42 cases before and 33 after) and the rate for those born in other nations actually increased by 24 percent (17 cases before, 21 after).
This article was originally published on BETA and something that I think we need to be having more discussion on here in Australia. It was first published on February 1, 2018,byEmily Land,
Last November, long-term survivors in San Francisco—and other interested community members—gathered to hear Ron Stall, PhD, from the University of Pittsburgh, present his research on AIDS Survivor Syndrome.
Organized by Tez Anderson, the director of the San Francisco nonprofit “Let’s Kick ASS” [AIDS Survivor Syndrome], the community forum offered a chance for long-term survivors to learn about a condition theorized to affect some people who have lived through the worst days of the AIDS epidemic.
During the community forum, Stall explained that what differentiates AIDS Survivor Syndrome from something like post-traumatic stress disorder (PTSD) is the length of time a person can be affected.
Anderson, for example, was diagnosed in 1987, and watched hundreds of friends and lovers pass away before effective HIV therapies were developed. His own health suffered, and every few years his doctors would tell him he didn’t have much more time to live. After living to see the roll-out of protease inhibitors and modern-day HAART in the 1990s, Anderson said the trauma of HIV started to take on a slightly different tenor.
“I started getting this creeping notion in the back of my mind that, ‘I may become an old person with HIV,’ which brought a new set of anxieties,” he said. “I didn’t plan for being old.”
Ron Stall, PhD
Stall said the term “AIDS Survivor Syndrome” is used to describe the constellation of physical, psychological and emotional symptoms that a person (either HIV-negative or HIV-positive) may experience after living through intense grief and trauma during the years of the AIDS epidemic and after.
Stall, using data from the Multicenter AIDS Cohort Study (MACS), has been studying AIDS Survivor Syndrome and how it affects people who have lived through the HIV epidemic. Started in 1983, the MACS is a study of more than 7,000 of men who have sex with men (both HIV-negative and HIV-positive) who complete twice-yearly health and behavioral assessments to study the health effects of HIV infection. Stall reported that as of 2013, the average age of people in the study was 56, and roughly half of the men (49%) were living with HIV.
More than a quarter (27%) of men surveyed in the study had lost more than 10 people close to them to AIDS. 35% of men reported that they “still grieve” for these lost people, 7% of men reported that they “still deeply grieve,” and 3% reported that they “grieve these losses nearly every day.” About half (49%) agreed with the statement that “Because of the HIV epidemic, I never thought I would live as long as I have.”
To assess AIDS Survivor Syndrome, Stall’s research team asked participants about symptoms they theorized constitute AIDS Survivor Syndrome, including depression, isolation, anxiety, difficulty sleeping, feelings of despair for the future, nightmares, emotional numbness, strong feelings of anger, and feeling threatened.
Half of the men in the cohort had none of these symptoms, while the rest reported experiencing one to all nine of these symptoms at some point over the last six months. Nearly a quarter of men (22%) reported experiencing three or more symptoms “fairly frequently.”
“Most of us are doing OK, or very well, but there is a small cluster of guys who probably really do need some kind of help in dealing with the long-term effects of the epidemic,” said Stall.
Stall’s research team tested the statistical “clusterness” of symptoms as a way to see how well they “hung together” as part of a related syndrome. (Stall explained that for a condition to be characterized as a “syndrome,” signs and symptoms would need to occur together.) All of the symptoms, except nightmares and trouble sleeping, were statistically linked.
Interestingly, said Stall, people in the study who were HIV-negative seemed to be as affected as men living with HIV.
“The [HIV] negative men are also suffering significantly from repercussions of the epidemic, it would appear,” said Stall. “I immediately thought of a friend of mine, that I was close to in San Francisco, who wears a chain around his neck with two wedding rings. He has buried two partners.”
“People who are HIV-negative, who lived through the AIDS epidemic may have survivors guilt,” said Dusty Araujo, a coordinator for the Elizabeth Taylor 50-Plus Network. “They maybe were in the trenches, too—caring for friends and watching them die. They were marching, protesting, and trying to create change. Some people who are HIV-negative went through the same struggles, so for them to find community and support is important, too.”
Crisostomo and Araujo said that it was not surprising to hear that such a large percentage of people in the Multicenter AIDS Cohort Study studied by Stall experienced symptoms including depression, anxiety, isolation, and fear.
“Although people may or may not identify with the ‘AIDS Survivor Syndrome’ term, these symptoms are present in our community. People may experience things like depression and isolation as they age—whether or not they were impacted by the AIDS epidemic,” said Araujo.
“This is the rationale for the Elizabeth Taylor 50-Plus Network and other community programs that benefit long-term survivors,” said Crisostomo. “We bring people together and build community. People have an opportunity to get out of their houses, engage with each other, connect to services, volunteer in the community, and learn from each other. All of those things can help people if they are experiencing things like isolation, depression, and loneliness.”
I’ve been working in sexual health since 2010 and I’ve seen it all.
I’ve seen how the lack of basic sex education can affect people. I’ve seen how low poor self-esteem can impact someone’s judgement to look after their sexual health. But of all I’ve seen, it’s fear that is having the biggest impact on HIV prevention by creating stigma associated with HIV.
Fear is the worst emotion of them all. Fear makes us afraid of things we shouldn’t find scary. When people are afraid they tend to back off, put up walls, criticise or lash out. Some won’t even believe the facts that are put in front of them. Fear in our community is stopping people from opening up and preventing communication with gay men living with HIV. Fear is leading to a battle within our community on apps and in social settings.
People with HIV are called ‘dirty’, ‘sluts’, ‘bad people’ because luck went against them and they caught the virus. Fear creates a space for targeted hate. Many times HIV-negative people hit out at people living with HIV because they are scared of the virus. But this can have severe health problems for people living with HIV. It’s been found that men living with HIV are likely to have mental health issues because of their status, with some dying by suicide. Four in ten suicides occurred in the first year after diagnosis. During this time, men’s suicide rate was five times that of the general population. This is totally unacceptable.
Over the last several years, GMFA and other sexual health organisations have worked really hard to make sure we reached out to people and help break down the fear associated with the virus. But unfortunately, fear also sells. And in a world where clicks are more important than improving society we are seeing how years of hard work can be destroyed with just one headline. And it’s so frustrating. I know what some of you are already thinking: “Isn’t fear a good thing sometimes, as it keeps us in check?” or thinking that stigma or having a fear of HIV-positive people will stop people from becoming positive.
Well I’m here today to tell you that you are wrong. Recently, Public Health England released statistics that show that about 13% of people who are living with HIV don’t know they have the virus. Those 13% think they are HIV-negative. They are also accounting for around 80% of new HIV infections. So it’s mainly people who don’t know they have HIV, who will tell you they are HIV-negative, who are spreading the virus. If you’re being treated successfully, you cannot pass on HIV.
Here’s something you need to know. People living with HIV and on successful treatment cannot pass on the virus. When someone is diagnosed as HIV-positive, their viral load (that’s the amount of HIV in their system) tends to be very high. Once they are put on HIV medication, the medication works to decrease the amount of HIV in their body and very soon their viral load will become so low that they will become HIV-undetectable, meaning there is so little HIV in their system they cannot pass on the virus. In the last year or so you may have seen this message being pushed quite a bit by sexual health organisations. It’s been proven by science.
The PARTNER study recorded sexual acts between mixed HIV status people and found that no-one passed on the virus. But yet, because of the fear people have we still have people not believing science. I’ve heard many times: “It’s not worth the risk”. But we must continue moving forward with this message. Fear can hold us back but education and awareness will move us forward. We must continue to work to dispel the ignorance that ‘s surrounding HIV, increase people’s knowledge of testing, treatment as prevention, PrEP and condoms, while breaking down the social barriers that are caused by fear and HIV stigma. Only by increasing our knowledge of HIV and how it’s transmitted, can we really make an effort to stop HIV stigma in our community.
Someone’s unfounded fear might just be stopping them from being with someone truly amazing.
This article was originally published in the i Newspaper.