HPA recommendations on HIV testing

The Health Protection Agency (HPA) has released the latest epidemiological data on HIV in the United Kingdom, showing that in 2011 an estimated 96,000 people were living with HIV, but that 24% of them were unaware of their infection.

And, among those who were newly diagnosed with HIV, 47% were diagnosed late (with a CD4 count below 350). While this is an improvement on 2002’s figure of 60%, several other countries do better in diagnosing people earlier. There are inequalities too, with heterosexual men and black African people most likely to be diagnosed late.

The HPA has found that few sexual health commissioners in high-prevalence areas have commissioned HIV testing in GP surgeries or in hospital admissions units, although BHIVA and NICE guidelines recommend this.

In the HPA’s annual HIV report, six of its eight recommendations concern testing, including:

  • Annual testing for men who have sex with men (MSM) – or every three months if having unprotected sex with new or casual partners
  • “Regular” testing for black African and Caribbean people who have unprotected sex with new or casual partners.
  • In high-prevalence areas, implementation of routine HIV testing for new GP patients and new hospital admissions.
  • Clinicians outside of sexual health settings should take every opportunity to offer HIV testing to MSM and black African or Caribbean people.

Patients dropping out of care and HIV prevention

A new focus of attention in the last year has been the HIV ‘treatment cascade’. There is concern that the impact of HIV treatment as a prevention tool is being compromised by the fact that not everyone with HIV is on treatment with an undetectable viral load.

This is because not everyone with HIV is diagnosed; not everyone who is diagnosed stays in medical care; not all those in care are taking HIV treatment; and not everyone on treatment has an undetectable viral load. The end result is that, of people living with HIV in the UK, an estimated 54% have an undetectable viral load.

Researchers are looking into the characteristics of people who drop out of HIV care in the UK, as well as into interventions that help patients stay in care.

Clinics may be able to reduce the number of patients who drop out by taking proactive steps to contact people who have not attended recently (by letter, phone call, or via the GP). There could also be a role for community organisations in supporting engagement with care, especially in African communities.

New evidence of treatment as prevention

A study of almost 39,000 heterosexual couples in China has provided further evidence that treatment has a prevention impact. The risk of HIV transmission was reduced by 26% in heterosexual couples where the HIV-positive partner was taking antiretroviral therapy, compared to couples where the HIV-positive partner stayed off treatment.

This is much lower than the 96% reduction in risk seen in the HPTN 052 trial, and may reflect what is possible in ‘real-world’ conditions in a middle-income country. There may be considerable problems with access to care, loss to follow-up, adherence to treatment and availability of second-line regimens. Also, the researchers could not check that an individual’s infection was genetically linked to that of their primary partner.

There was a clear reduction in transmissions during the first year of follow-up, but not in subsequent years.

While this study provides further evidence of the prevention benefits of HIV treatment, the lower reduction in risk than that seen in a clinical trial underlines the importance of good clinical care for treatment to work as a prevention tool.

ART beliefs and risky sex

A study with over 2000 HIV-positive gay men attending UK clinics looked at risky sex and antiretroviral treatment (ART) beliefs.

One-in-seven men reported having sex without a condom with a partner who wasn’t HIV positive, which is comparable to other studies.

The study found that there was an association between men’s beliefs about treatment-as-prevention and their behaviour. Those who didn’t think that an undetectable viral load makes you less infectious (almost half the men) were the least likely to report risky sex. The very few men (4%) who thought that an undetectable viral load made condoms superfluous were five times more likely than others to report risky sex.

But actually taking treatment was not associated with having risky sex – in fact, men on treatment were slightly less likely to do so, although this wasn’t statistically significant.

A key finding of the study was that a large number of men continue to believe in the importance of using condoms, even with an undetectable viral load.

The data have implications for prevention strategies, particularly in terms of the complex question of whether making people aware of the prevention benefits of treatment may increase risky behaviour.

Young people born with HIV

A study from the United States has shed light on the sexual behaviour of adolescents born with HIV, many of whom are putting their own sexual health at risk as well as that of their partners.

In this study of 330 people aged 10 to 18, all of whom have been living with HIV since birth, over half had had sex by the age of 16 and 87% by the age of 18.

Of those who had had sex, 62% had not always used a condom. Moreover, a significant proportion of this group had a detectable viral load and drug-resistant virus.

Young people who did not use a condom were also less likely to have disclosed their HIV status.

In the past two years, UK studies have also highlighted the complex needs of young adults who were infected at birth, including problems with disclosure, relationships, anxiety and adherence. Around one-in-seven adolescent females have been pregnant, with most pregnancies being unplanned.

In order to guide health professionals, the HIV in Young People Network (HYPNET) and the Children’s HIV Association (CHIVA) publish guidance on supporting adolescents living with HIV with their sexual and reproductive health.

Mother-to-child transmission

An Italian study has found that 20% of women with HIV overestimated the likelihood of passing on HIV to their babies if they were on HIV treatment – nearly 10% thought that transmission from a mother with HIV to a child was more than 50% likely.

Fear of mother-to-child transmission was the strongest predictor of a woman reporting that she did not want to have children.

While the UK situation may be slightly different, the study highlights the importance of providing basic factual information on this topic. As well as helping to reduce the number of HIV infections in babies, providing such information may improve the psychological well-being of women living with HIV and help to reduce stigma in the wider community.

MBARC’s role in HIV Prevention England

MBARC is one of six partners making up HIV Prevention England, the new national HIV prevention programme that is targeted towards men who have sex with men and African communities.

Set up in 1993, MBARC (previously known as Michael Bell Associates) is a company that provides research, consultancy and programme management services. Much of its work for NHS and local authority commissioners has focused on sexual health and social exclusion.

Within HIV Prevention England, MBARC has two main roles.

Firstly, it works alongside Terrence Higgins Trust to provide ‘development and engagement’ work with commissioners, service providers and businesses. Recent work in this area has included presentations and briefings for commissioners to prepare them for National HIV Testing Week.

MBARC has also developed the tender process for organisations that wish to become local delivery partners in the partnership.

Secondly, MBARC is one of three organisations commissioning and co-ordinating local HIV prevention work. The three organisations are:

  • MBARC (work with gay communities in London and southern England)
  • Yorkshire MESMAC (work with gay communities in central and northern England)
  • BHA (work with African communities across England).

Each works with a network of local delivery partners which deliver activities in support of national HIV prevention campaigns, including engagement with NHS clinics, commissioners and businesses, as well as interventions within communities.

Related links

Other recent news headlines

UK clinicians define minimum standards of HIV care – for a changing NHS

The British HIV Association (BHIVA) recently published a document that outlines the standard of care that people with HIV should expect to receive – whoever is providing it. Read more >>

Sharing drug preparation equipment a potential source of hepatitis C transmission

Drug users who share injecting equipment such as water, filters and water containers are potentially putting themselves at risk of infection with hepatitis C virus, according to German research published in the online edition of the Journal of Infectious Diseases. Read more >>

Couples HIV testing and counselling prompts rapid switch to consistent condom use in South African study

HIV testing and counselling of couples quickly led to consistent condom use among serodiscordant couples in stable relationships in South Africa, researchers report in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes. Read more >>