UK position statement on HIV treatment as prevention

The British HIV Association (BHIVA) and the Department of Health’s Expert Advisory Group on AIDS (EAGA) published last month a position statement on the use of HIV treatment by people with HIV to reduce the risk of transmission. For the first time, the document provides health professionals with a consensus statement, developed by UK experts, which can be used to guide discussions with individuals.

Clinicians, epidemiologists, policy experts and HIV-positive people contributed to the document. As this will be a key resource to guide HIV prevention work in England, a substantial part of this bulletin is given over to outlining its key points.

As effective as condoms

The statement notes that there is now conclusive randomised clinical trial evidence, from the HPTN 052 trial, to show that transmission of HIV through vaginal sex is significantly reduced when an HIV-positive person is taking effective antiretroviral therapy (ART). In this trial, early treatment reduced HIV transmission to an uninfected partner by 96%.

“The observed reduction in HIV transmission in a clinical trial setting demonstrates that successful ART use by the person who is HIV positive is as effective as consistent condom use in limiting viral transmission,” it says.

The document includes some explanatory notes, which point out that there has never been a randomised controlled trial of the efficacy of condom use, compared to non-use. For that reason, there are no figures that can be directly compared. However, meta-analyses of observational studies of serodiscordant couples who maintained 100% condom use have found the strategy to be about 80% effective in reducing HIV infection.

Necessary conditions

The document states that the transmission risk during vaginal intercourse will be “extremely low”, provided certain conditions are fulfilled.

  • There are no sexually transmitted infections in either partner. (The document clarifies requirements for STI screening, including following sexual relationships outside a primary partnership.)
  • The person with HIV has had a sustained plasma viral load below 50 copies/ml for more than six months, including the most recent test.
  • Viral load testing occurs every three to four months (i.e. more regularly than in standard clinical care).

In the document’s explanatory notes, it is explained that in HPTN 052 there was a single confirmed case of HIV transmission from a person on treatment. This individual had only recently begun ART and would not have met the UK position statement’s requirement for an undetectable viral load for at least six months.

The authors say that this justifies the use of the phrase “extremely low risk”. They clarify that this is not the same as “zero risk”. Moreover, with the data that are available, it is not possible to give accurate and meaningful figures for the risk of transmission during a single sexual act.

Anal intercourse

The published research was primarily done with heterosexual couples and is assumed to relate primarily to vaginal intercourse. Data are not available for anal intercourse, either between men, or between men and women. “However, it is expert opinion that an extremely low risk of transmission can also be anticipated for these practices, provided the same conditions stated above are met,” according to the statement.

Limitations of ART

The position statement notes that no single prevention method can completely prevent HIV transmission. Moreover, antiretroviral treatment has no effect on other sexually transmitted infections, whereas condoms can prevent their spread.

Discussion with people with HIV

Healthcare professionals should discuss the impact of ART on sexual transmission with all people living with HIV. For people not currently on therapy, the possibility of starting treatment in order to reduce transmission risk should be discussed. (BHIVA treatment guidelines already make a similar recommendation).

It is important that these discussions cover the ‘necessary conditions’ for ART to reduce transmission risk - long-term adherence, frequent STI screening and regular viral load measurements.

Incidence in gay men: the impact of condom use, testing and treatment

Two mathematical modelling studies published this month suggest that higher rates of testing, earlier treatment and sustained condom use are all important in limiting new infections among gay men in the UK.

In the first study, researchers fed data on diagnoses, CD4 counts at diagnosis, and the proportion of people on antiretroviral therapy (ART) into a mathematical model. Although the number of new diagnoses increased between 2001 and 2010, the true annual total of HIV infections (both diagnosed and undiagnosed) changed very little – around 2200 to 2300 gay men every year.

During this decade, gay men have taken more tests (up from 16,000 to 59,300 in 2010) and more diagnosed men have started HIV treatment (up from 69% to 80%). But testing is still far from frequent enough and a significant number of men continue to have risky sex.

A second mathematical modelling study used a different range of data and a different set of assumptions in order to estimate incidence, sexual risk behaviour and what could have happened if sexual and medical practices had been different. The results suggested that incidence has risen slowly since 2000. Moreover, the model found that modest increases in condomless sex have led to a rise in infections, but that there would have been far more infections (68% more) if HIV treatment had not reduced the infectiousness of gay men with diagnosed HIV.

Both studies suggest that the following are key to controlling the HIV epidemic in men who have sex with men – continued and increased use of condoms; far more frequent and better targeted HIV testing; and beginning HIV treatment at higher CD4 counts or as soon as diagnosed.

Crystal meth in London

Media reports have raised concern about the use of the drug crystal meth (methamphetamine) amongst London gay men, and linked to its use to HIV and hepatitis C infections, including some through needle sharing.

But there is not much reliable information about the use of crystal meth. The data which suggest a recent upsurge in the use of the drug come from specialist clinics and services which see a limited number of individuals.

Larger surveys of gay men, most of them carried out a few years ago, suggest that the scale of the problem is limited. The surveys indicated that users of crystal meth were quite similar to gay male users of other drugs.

Limited impact of acute infection campaign

An intervention which aimed to raise awareness among gay men in of the symptoms of acute HIV infection (very recent infection, also known as primary infection) had a limited impact on knowledge and behaviour.

In London around one-in-four new infections come from people with undiagnosed acute infection. So prompt testing during this period could be make a difference, and one possible approach is to increase people’s knowledge about the symptoms of recent HIV infection – flu-like symptoms, fever, rash, joint and muscle aches, etc.

The ‘ru2hot?’ campaign aimed to do this for gay men in Seattle. With a limited budget, around one quarter of its target audience remembered seeing it, but there were few changes in their knowledge of symptoms. Moreover, the number of men diagnosed during acute infection in Seattle did not change.

This evaluation should be studied by UK prevention workers considering a campaign on this theme.

Circumcision in UK gay men

A survey of white, British-born men who have sex with men in the UK has confirmed that circumcision is unlikely to protect gay men from HIV.

While one or two studies have found that circumcision is protective of gay men who take the insertive role during anal intercourse (‘exclusive tops’), a greater number of studies could not reproduce those findings. Indeed, in the new UK study there was no statistical association between circumcision and HIV status, even in exclusive tops.

African epidemic fuelled by high viral loads

Researchers have found that the average HIV viral load of people not taking HIV treatment in Africa, and especially in southern and eastern Africa, is higher than in other parts of the world. The ‘community viral load’ off treatment was on average nearly four times higher in sub-Saharan Africa than it was in North America.

Greater numbers of untreated co-infections (malaria, tuberculosis, herpes, etc.) may be responsible for the higher community viral loads in Africa. The researchers speculate that the higher viral loads may have contributed to the explosive HIV epidemics seen in African countries, having a particular impact on the likelihood of lower risk individuals (for example, heterosexual people with fewer partners) acquiring HIV.

NAM’s role in HIV Prevention England

NAM, the organisation that produces this bulletin, is one of six partners making up HIV Prevention England, the new national HIV prevention programme.

NAM was founded in 1987 and is dedicated to providing independent, clear and accurate information about HIV to anyone who needs it. As well as HIV treatment information and listings of HIV services, NAM has long provided information on HIV prevention, including the comprehensive resources Preventing HIV and HIV Transmission & Testing.

Within HIV Prevention England, NAM has two roles. Firstly, it is responsible for disseminating new epidemiological data, research findings, evaluations of interventions, guidance and policy developments to partners and the wider HIV sector in England. This is done primarily through this monthly bulletin, but also through the Aidsmap website. The aim of this work is to help ensure the programme is guided by the latest evidence.

Secondly, NAM has a key role in clinical engagement, in other words making connections between HIV Prevention England and sexual health clinicians. Working with GUMNet (a grouping of 29 of the larger genitourinary medicine services) and other clinics, NAM will make prevention resources available in clinics and provide a means for clinical staff to feed back on campaigns and contribute to their development.

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