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Wednesday 30th July 2014

Contents

Coverage of AIDS 2014

This is our final summary bulletin from the 20th International AIDS Conference (AIDS 2014).

We hope you have found our news reports and bulletins informative and useful. You can find all our news coverage – including the six conference bulletins in English, French, Spanish, Portuguese, Italian and Russian – and selected news and tweets from other sources on our conference webpages at www.aidsmap.com/aids2014

We report on HIV and related news all year round, as well as producing information resources for people living with HIV and people working in the HIV field. You can sign up for our regular news bulletins, browse our publications, or make a donation to support our work, on our website www.aidsmap.com.

Key affected populations at the centre of AIDS 2014

Gottfried Hirnschall, Director of the HIV Department at the World Health Organization (WHO), speaking at AIDS 2014. Photo: International AIDS Society/Steve Forrest.

If there was a phrase that defined the 20th International AIDS Conference (AIDS 2014), it was ‘key affected populations’.

The World Health Organization (WHO) released its new Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations on 11 July.

These guidelines set out the priority services and interventions that should be provided to meet the needs of people who inject drugs, sex workers, men who have sex with men, transgender people and people in prison. Members of these groups are at high risk of HIV infection in all settings but their needs have been neglected in many parts of the world.

AIDS 2014 included numerous sessions looking at the issues faced by key populations.

Harm reduction for people who inject drugs

Olga Varetska, of the International HIV/AIDS Alliance Ukraine. Photo: ©IAS/MarcusRose/Workers' Photos.

Although there is a strong international scientific consensus that harm reduction is the most effective means of preventing HIV infection among people who inject drugs, some countries choose not to implement provision of sterile injecting equipment and opioid substitution therapy. Two strong examples of the impact of harm reduction on national HIV epidemics were presented at AIDS 2014, showing why harm reduction is a good investment.

Looking at the impact of Ukraine’s harm reduction programme between 2005 and 2013, Olga Varetska of International HIV/AIDS Alliance Ukraine, reported that HIV diagnoses among people who inject drugs began to decline in 2011 and have fallen by over 75% in young people who inject drugs since 2006, the best proxy for recent infections.

However, HIV infections among heterosexuals have risen sharply and now predominate, emphasising the importance of HIV prevention to prevent sexual transmission from male drug users to their partners.

In Greece, the expansion of harm reduction in response to an outbreak of HIV among people who inject drugs resulted in a dramatic reduction in HIV incidence between 2011 and 2013. Greek researchers used incidence data to estimate the impact of the programme. They calculated that HIV incidence was 88% lower than it would have been without scaled-up harm reduction.

The conference also heard a new recommendation on the prevention of overdose in people who inject drugs.

WHO’s Philip Read told the conference that more people who inject drugs now died of heroin overdoses than AIDS and that 60% of overdoses occur in front of another person.

WHO now recommends that people who inject drugs should be provided with emergency packs of the heroin antidote naloxone for use by friends or by the users themselves in case of accidental overdose.

Men who have sex with men

Luiz Loures, of UNAIDS, speaking at AIDS 2014. Photo: ©UNAIDS.

A survey of young gay men and transgender women in Bangkok has found that HIV incidence is running at 9% a year in those who don’t used condoms consistently – and 2% a year in those who say they do.

What can we do to prevent HIV in such a fast-growing epidemic, which is by no means unique to Thailand?

Luiz Loures of UNAIDS, who was chairing the session, commented: “It is a huge problem that young gay men today are coming out into a population where, already, a much higher proportion of their contemporaries has HIV than was the case 20 years ago.”

The Thai Red Cross, which runs the largest HIV clinic in Bangkok, is setting its sights on trying to get men who have sex with men (MSM) to test as frequently as possible in the hope of catching early infections; this is the inspiration behind the ‘Suck. F***. Test. Repeat.’ campaign which has garnered praise for its videos but also criticism for not including condom use in its text.

Pre-exposure prophylaxis (PrEP) using antiretroviral drugs is another potential option for HIV prevention among MSM, although largely unavailable outside the United States.

In its key population guidelines, the World Health Organization recommends PrEP as an additional prevention option for MSM. A survey conducted in Australia and the Netherlands found low awareness of PrEP among HIV-negative gay men, but strong interest among a subset of men who reported recent unprotected anal intercourse with a casual partner.

Qualitative research found that gay men in the two countries perceived PrEP to be a highly effective prevention method that could reduce anxiety about contracting HIV and allow greater intimacy with a partner, especially in a serodiscordant relationship (in which one person is living with HIV and the other is HIV negative). However, gay men expressed concerns about the cost of PrEP and how to obtain access to it. They also expressed concerns about their ability to take it consistently, and about possible side-effects.

HIV prevention for sex workers

The Official AIDS March to Federation Square. Photo: International AIDS Society/Steve Forrest

While consistent condom use is generally high among female sex workers, the same populations report lower rates of condom use with regular partners, pointing to a potential gap in HIV prevention strategies and potential for transmission to and from regular partners.

A study in six Central American countries found that 80% of female sex workers reported consistent condom use with clients, but a lower proportion reported consistent condom use with regular partners (30-60% by country) and rates of HIV testing varied widely across the region. A combination of behaviour change communication, free condom provision and HIV counselling and testing was associated with a threefold increase in condom use with regular partners.

The efficacy and acceptability of pre-exposure prophylaxis has not been tested with female sex workers, but a study modelling its impact in India found that 23% of HIV infections among female sex workers could be prevented over a ten-year period if at least 40% of sex workers used PrEP. 

Self-testing

Rachel Baggaley, of the World Health Organization (WHO). Photo©International AIDS Society/Marcus Rose/Workers' Photos.

Self-testing for HIV has great potential to broaden access to HIV testing, conference delegates were told.

It’s not clear how self-testing will be made available, but the World Health Organization set out some possibilities:

  • Open-access and unsupervised, with sales or distribution through retail pharmacies, websites or vending machines (the dominant model in the United States).
  • Some restrictions on access, with tests available from outreach workers, pharmacists or clinicians. Eligibility criteria might be more or less strict, depending on national policies and the epidemiological context.
  • Supervised self-testing, with additional support from a health worker or community volunteer, such as a demonstration of how to use the test or referrals to additional services.

However, research conducted in Kenya, Malawi and South Africa by PATH found a high frequency of user errors when using existing self-testing kits. Half of people filmed while using a kit made multiple errors as a result of difficulties in understanding the instructions or design flaws in the test kits. Similar problems arose in a separate study in South Africa. PATH is now trying to develop a more user-friendly self-test kit in partnership with industry.

However, manufacturers need to know more about how self-testing will be used, not just by individuals but also within programmes, before committing resources to developing new test kits.

More work is also needed to define how people who test positive should be linked to confirmatory testing and care.

Option B+ for treatment of mothers and prevention of vertical transmission

The lifelong offer of antiretroviral therapy (ART) to women living with HIV who are pregnant or breastfeeding, regardless of CD4 cell count – known as Option B+ – was pioneered by Malawi’s Ministry of Health in order to simplify the implementation of ART for prevention of vertical transmission (from mother to child). Malawi began implementing the policy in 2011.

The policy has also been adopted in Uganda, Rwanda and Haiti, and will be implemented from January 2015 in South Africa.

But how is Option B+ working in practice?

The number of women starting ART during pregnancy and breastfeeding increased sevenfold during the first 15 months after Option B+ was introduced, but research presented at AIDS 2014 shows almost one-in-four women are lost to follow-up in the first year after starting treatment. Among women traced after loss to follow-up, distance to the clinic and travel costs were the most frequently cited reasons for missing appointments.

However, a survey of 141 health facilities in south-eastern Malawi found that referring mothers living with HIV to a clinic where ART could be managed resulted in better retention than initiating ART in an antenatal clinic and then referring the mother later on.

A second survey, comparing national performance in both prevention of mother-to-child transmission (PMTCT) and early infant diagnosis found that although Malawi did well at getting mothers onto ART, it did less well at early infant diagnosis and provision of cotrimoxazole to HIV-exposed infants.

The survey assessed the performance of six PMTCT interventions in Malawi, Lesotho, Tanzania and Zambia between November 2011 and February 2012.

While 71% of pregnant women received antiretrovirals during pregnancy in Malawi, only 5% did so in Tanzania. However, 58% of HIV-exposed infants had been tested for HIV by eight weeks of age in Tanzania, compared to 17% in Malawi and 83% in Lesotho.

Researchers concluded that early infant diagnosis could be improved by:

  • A family-centred approach so mothers and infants get services from the same place
  • Integration of paediatric HIV care into routine maternal and child health services
  • Point-of-care diagnostics to minimise loss to follow-up, long turnaround time and late initiation of care and treatment.

STEP – A community initiative to design the pathway to long-term remission of HIV

The European AIDS Treatment Group (EATG) is organising STEP, a community training day. 

The training will look at research into strategies for long-term remission of HIV infection off antiretroviral therapy (often referred to as ‘cure’ research).

It will take place in Glasgow on Saturday, 1st November 2014 (in advance of the HIV Drug Therapy Congress).

Participation in the training is open to all community members with an interest in this area.

Depending on the funding available, EATG will offer up to 30 scholarships for community members, to cover accommodation the night before the meeting.

If you wish to attend, please fill in the online registration form.

For more information on the training, please contact Giulio Maria Corbelli: giuliomariacorbelli@gmail.com

Scientific analysis from Clinical Care Options

Clinical Care Options' (CCO) is the official online provider of scientific analysis for delegates and journalists.

Over the next few weeks, their coverage will include expert audio highlights, capsule summaries of important clinical data, downloadable slidesets, and more.

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NAM’s AIDS 2014 bulletins have been made possible thanks to support from Bristol-Myers Squibb. NAM's wider conference news reporting services have been supported by AbbVie, Gilead Sciences, Janssen and ViiV Healthcare’s Positive Action Programme.