Health and wellbeing boards' priorities

In areas of high HIV prevalence in England, half the local authorities have not made HIV a public health priority, according to an analysis conducted by HIV Prevention England partners and presented at the British HIV Association (BHIVA) conference in Manchester last month.

In each local authority area, the health and wellbeing board is meant to produce a strategy document as well as a Joint Strategic Needs Assessment. These two documents outline priorities for public health commissioning and service provision.

Looking at England’s 35 highest-prevalence areas, in 18 of them the strategy documents did not make HIV a priority. This happened in some of the most-affected parts of the country, including Brighton & Hove, Camden and Islington.

Some local areas had much better practice, and did address HIV in an effective, targeted and outcome-driven way. Merton in South London was given as an example.

Speakers at the BHIVA conference recommended that service providers, clinicians, people with HIV and members of the public should engage with their local health and wellbeing board and shape their agenda.

GPs and HIV testing

A multifaceted educational intervention for doctors and practice nurses working in general practice in London led to a tripling in the number of HIV tests provided, according to an evaluation.

As printed information and meetings for clinicians don’t always have much impact on clinical practice, the intervention delivered in Haringey, London, mixed role play, interactive sessions and didactic teaching. Communication skills, risk assessment and staff confidence were addressed in the programme. Much of the training was delivered by local GPs and practice nurses.

In GP practices which sent staff on the training, the number of HIV tests conducted tripled from 2.29 tests for each 1000 patients each year, to 6.66 tests per 1000 patients. Around 1.5% of tests resulted in a positive diagnosis. There was no similar rise in GP practices whose staff did not take part.

The researchers say that this evaluation demonstrates that commissioning of the Sexual Health in Practice programme for general practices is likely to support the implementation of increased HIV testing and diagnosis in primary care.

Drugs and risky sex

A survey of over 3000 HIV-negative men who have sex with men in San Francisco suggests that there is a significant relationship between frequency and intensity of drug use and risky sex.

Men who used cocaine occasionally (less than once a week) were twice as likely as non-users to report unprotected anal intercourse (UAI) with a man of unknown HIV status, or with an HIV-positive man. Men who used cocaine more often than this were three times as likely as non-users to report this risky sexual behaviour.

Men who used crystal methamphetamine occasionally were three times as likely to report risky sex. More frequent users were five times as likely to have UAI with a man of unknown or positive HIV status.

Looking at alcohol use, there wasn’t such a clear relationship, although heavy drinkers did have more risky sex than moderate drinkers.

The research also suggests that using two or more substances together was associated with an increased risk of UAI being with a man of unknown HIV status.

The authors say that gay men who use drugs or alcohol “may benefit from strategies that build self-efficacy and promote skills for explicit HIV-serostatus communication with partners”.

Vaccine research

In a blow to HIV vaccine development, American researchers have announced that they are discontinuing the HVTN 505 HIV vaccine trial. This trial of 2504 volunteers started in July 2009 and was testing an investigational ‘prime-boost’ vaccine regimen.

Since the successful conclusion of the RV144 vaccine trial in September 2009, HVTN 505 has been the only ongoing HIV vaccine trial large enough to be a true test of vaccine efficacy.

The trial’s data and safety monitoring board (DSMB) found that the vaccine regimen was neither preventing HIV infection nor reducing viral load among vaccine recipients who acquired HIV. There were actually more HIV infections in volunteers receiving the vaccine than placebo, but this difference was not statistically significant and could be due to chance.

Viral load and unprotected sex

Analysis of a survey of gay men living with HIV in the Netherlands, focused on respondents who had an undetectable viral load, found that 41% of them sometimes take viral load into account when deciding whether or not to have unprotected sex. This represents about two-thirds of the men who actually did have unprotected sex.

The survey found that consideration of viral load was as common when having sex with partners who also had HIV as when having sex with partners of negative or unknown status. With HIV-positive partners, men were presumably concerned about superinfection.

Open discussion of viral load was quite common with HIV-positive partners, whereas it was rarely discussed with partners assumed to be HIV negative ­– the positive man tended to consider on his own how likely he was to transmit HIV.

This was a subset (177 men) of a small survey (212 men), conducted with individuals who are part of a consultation panel for a Dutch HIV advocacy organisation. It’s possible therefore that the sample is more engaged and informed than other men with HIV.

Nonetheless, this study suggests that a significant number of men with HIV are already taking viral load into account in their sexual decision making.

However, few HIV prevention resources address this issue in a detailed and practical manner, and it is likely that HIV educators could do more to help men make fully informed sexual decisions, incorporating consideration of viral load.

Herpes viruses and detectable viral load

Meanwhile, another study has suggested that low-level HIV viral load in the blood and shedding of cytomegalovirus (CMV) and Epstein Barr virus (EBV) in semen are associated with detection of HIV in the genital tract.

This was a study of 114 men who have sex with men who were taking HIV treatment. Almost all (88%) participants had an undetectable blood plasma viral load (below 50 copies/ml), with the remaining 12% having a viral load between 50 and 500 copies/ml. Generally, adherence was good and CD4 counts were above 500 cells/mm3.

As expected, the study found a strong correlation between HIV being undetectable in blood and in semen.

Nonetheless, 10% of participants had low levels of detectable HIV in their semen. Men with detectable HIV in semen were more likely to have active infection of two viruses of the herpes family: cytomegalovirus (CMV) and Epstein-Barr virus (EBV). Men with high levels of these viruses in their semen were respectively 4.5 and six times more likely to also have detectable HIV in their semen.

It is already well known that sexually transmitted infections can cause temporary rises in viral load, but CMV and EBV having the same effect has not been observed before. These viral infections are extremely common across the population but do not usually cause symptoms or need treatment, so tend not to be monitored.

Nonetheless, the detectable HIV viral loads in semen remained fairly low (median 126 copies/ml). It’s not clear how infectious a person with this viral load actually is.

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