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HIV+ men with undetectable viral load do not transmit HIV to their partners, says new study

HIV-positive men who are on treatment and have undetectable viral load do not transmit HIV to their partners.

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PARIS, FRANCE – HIV-positive men who are on treatment and have undetectable viral load do not transmit HIV to their partners. This is according to new study – titled “Opposites Attract” – from the Kirby Institute at the University of New South Wales (UNSW) in Australia, and presented at the International Aids Society (IAS) Conference on HIV Science in Paris, France.

For this study, 358 serodiscordant gay male couples (where one has HIV and the other does not) from Thailand, Brazil and Australia were regularly tested from 2012 to 2016. For that period, the researchers recorded 16,889 acts of condomless anal sex, and none of those acts resulted in the transmission of HIV.

“Our research adds to the evidence from a small number of other international studies of heterosexual and homosexual couples and means that we can say, with confidence, that effectively treated HIV blocks transmission in couples of differing HIV status,” said Andrew Grulich, the study’s chief investigator and a professor at the Kirby Institute.

Already, an earlier PARTNER study found that HIV-positive people on effective HIV treatment that fully suppresses their virus cannot transmit their infection through sex.

Both the “Opposites Attract” and the PARTNER studies also found that if the HIV-positive partner is on successful treatment, even having another sexually transmitted infection (STI) does not increase the risk of HIV being transmitted. In “Opposites Attract”, participants had an STI during 6% of anal sex acts; while in the PARTNER study, 17.5% of participants had an STI at some point in the study.

Sexual positions also did not matter even though when viral load is not suppressed, transmission is 10-20 times more likely if the HIV-positive partner is the insertive one (i.e. “top”). In “Opposites Attract”, the HIV-positive partner was “top” over a third of the time.

Three men actually became infected with HIV during the “Opposites Attract” study. However, genetic analysis showed that these infections came from a partner outside the main relationship who was not virally suppressed.

The results of “Opposites Attract” strengthen the “U=U” (Undetectable=Untransmittable) campaign of the Prevention Access Campaign, whose consensus statement was signed by the International AIDS Society (IAS) and NAM, organizers of the conference in Paris.

For Kevin Robert Frost, CEO of amfAR, one of the organizations that funded the study, these results are “extremely encouraging and underscore the need to get people tested and onto treatment immediately if they are HIV positive,” he said in a statement released to the media. “This important breakthrough underscores yet again how investments in HIV research yield invaluable dividends in the global response to HIV.”

REFERENCE
Bavinton B et al. (presenter Grulich A). HIV treatment prevents HIV transmission in male serodiscordant couples in Australia, Thailand and Brazil. 9th International AIDS Society Conference on HIV Science, Paris, abstract no TUAC0506LB, July 2017.

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Study links low immunity to poor outcomes in patients with HIV who contract COVID-19

“When we have vaccines, our goal is to identify the most vulnerable populations. Patients with HIV should be a priority target when we are looking at any measure that could improve outcomes for patients at high risk for complications with COVID-19.”

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Clinical trials are testing whether medications that treat human immunodeficiency virus (HIV) can also treat COVID-19, leading some patients with HIV to believe they might be protected against the coronavirus. But a researcher from the MU School of Medicine not only found patients with HIV are susceptible to the virus, she also discovered which factors increased the risk of hospitalization and death.

Principal investigator Dima Dandachi, MD, assistant professor of clinical medicine, examined data that included 286 adult patients with HIV who were diagnosed with COVID-19 across 36 institutions in 21 states. Within 30 days of COVID-19 diagnosis, 57% of the patients required hospitalization, 16% required ICU admission and 9% did not survive. In the study, more than 94% of patients were actively taking HIV medication.

“We were able to show that patients with HIV who are actively taking their medication are just as susceptible to COVID-19 as the general public,” Dandachi said. “And those with low immunity uncontrolled HIV or newly diagnosed HIV are at a higher risk of hospitalization or death. The key message for these patients is to take precautions against contracting the virus while ensuring they are compliant with their HIV medications to raise their immune cell count as high as possible.”

Dandachi and her team of researchers found people with HIV older than 60 and those with chronic health issues also had a much higher risk of being hospitalized or dying from COVID-19.

“The medications that prolong the lives of patients with HIV have improved life expectancy, but now we are seeing these patients develop other chronic conditions such as obesity, diabetes and heart disease that we didn’t see 15 years ago,” Dandachi said. “And when we looked at the data from this study, we found that lung disease, kidney disease, hypertension and older age were associated with higher hospitalization rates, higher ICU admissions and increased mortality from COVID-19.”

As a researcher-clinician who treats patients with HIV, Dandachi will use this study to counsel her patients to best protect themselves against COVID-19 while also using it as proof that this patient population should be among the first considered for protection once a vaccine is developed.

“When we have vaccines, our goal is to identify the most vulnerable populations,” Dandachi said. “Patients with HIV should be a priority target when we are looking at any measure that could improve outcomes for patients at high risk for complications with COVID-19.”

Dandachi’s study, “Characteristics, Comorbidities, and Outcomes in a Multicenter Registry of Patients with HIV and Coronavirus Disease-19,” also featured contributions from Mojgan Golzy, PhD, an assistant research professor in the Department of Health Management and Informatics; and MU School of Medicine students Grant Geiger and Maraya Camazine. It was published by the journal Clinical Infectious Diseases.

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Study supports WHO recommendation to use dolutegravir as first-line HIV treatment; efavirenz an alternative option

A study supports the current recommendation from the World Health Organization to use dolutegravir as first-line treatment for HIV, with efavirenz as an alternative option. However, the study also suggests that dolutegravir should be combined with TDF/FTC, which is associated with suppression of weight gain.

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A study supports the current recommendation from the World Health Organization to use dolutegravir as first-line treatment for HIV, with efavirenz as an alternative option. However, the study also suggests that dolutegravir should be combined with TDF/FTC, which is associated with suppression of weight gain, and not with the newer combination of TAF/FTC, which is associated with excess weight gain and clinical obesity, especially in women.

For the ADVANCE research study, conducted in central Johannesburg in South Africa, over 1,000 participants were recruited from routine HIV services in and around the inner city area of Hillbrow. Data was cross-analyzed with two of the current Department of Health antiretroviral regimens, recommended in the 2019 ART guidelines, and a third regimen favored by higher-income countries. The newer regimens appeared to have side effect and resistance benefits over older regimens, and potential cost benefits, but little research had been done on non-Western populations with them.

All three regimens were very potent and well tolerated by patients; however, the newer regimens containing dolutegravir (DTG) and tenofovir alafenamide (TAF) demonstrated a large increase in weight, especially in women.

After 96 weeks of treatment, the percentage of people with viral suppression was 79% in the TAF/emtricitabine (FTC)+DTG arm, 78% in the TDF (tenofovir disoproxil fumarate)/FTC+DTG arm and 74% in the TDF/FTC/EFV (efavirenz) arm.

There were no significant differences in overall efficacy between the three treatments tested.

In terms of weight gain, after 96 weeks of treatment, men gained 5.4 kg in the TAF/FTC+DTG arm, 3.6 kg in the TDF/FTC+DTG arm, and 1.1 kg in the TDF/FTC/EFV arm.

For women, at the same time point, the weight gain was 8.1 kg in the TAF/FTC+DTG arm, 4.8 kg in the TDF/FTC+DTG arm, and 3.2 kg in the TDF/FTC/EFV arm.

The treatment emergent obesity for women at week 96 was 28% for those on TAF/FTC+DTG (5% for men), 18% for those on TDF/FTC+DTG (4% for men), and 12% for those on TDF/FTC/EFV (3% for men).

Dr Simiso Sokhela, lead clinician on the study, commented: “We are concerned about the weight gain and body composition changes which are more severe in women, and we have predicted new risk of associated diabetes and other complications, especially when taking both TAF and DTG together. The 96 week results supports the WHO treatment guidelines which reserve TAF only for patients with osteoporosis or impaired renal function.”

The study team suggest that service providers should consider the best options for patients to reduce their risk of long-term co-morbidities, and should consult with patient groups, researchers and other expert groups for guidance.

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Short-term use of HIV-prevention medication protects at-risk men on vacation

Short-term use of pre-exposure prophylaxis (PrEP) medication could be a highly successful way to prevent the spread of HIV in men who have sex with men and have difficulty with long-term PrEP use. It may also work to transition men to long-term PrEP use, which has been shown to be highly effective in reducing HIV transmission.

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Even if Filipinos still can’t widely access pre-exposure prophylaxis (PrEP)…

Men at particular risk for HIV are very likely to consistently take prevention medication during vacations when their odds of contracting the virus are higher, according to a new study led by scientists at the University of Pittsburgh Graduate School of Public Health, The Fenway Institute and Harvard University.

The findings, published in the Journal of Acquired Immune Deficiency Syndromes, indicate that short-term use of pre-exposure prophylaxis (PrEP) medication could be a highly successful way to prevent the spread of HIV in men who have sex with men and have difficulty with long-term PrEP use. It may also work to transition men to long-term PrEP use, which has been shown to be highly effective in reducing HIV transmission.

“We started this as a feasibility study to see if we could identify barriers to short-term PrEP use and make adjustments. But we were excited when we got the results and discovered that almost all the participants were adherent to the point of protection against HIV,” said lead author James Egan, Ph.D., M.P.H., assistant professor of behavioral and community health sciences at Pitt Public Health. “This gives us a promising strategy to pursue in engaging at-risk men in HIV prevention efforts that work for them.”

When taken as a daily pill, PrEP reduces the risk of getting HIV from sex by about 99%, according to the Centers for Disease Control and Prevention. However, adhering to a daily medication regimen doesn’t work for everyone for reasons that include cost and individual concerns about the biological consequences of long-term medication.

Previous studies have shown that there are certain periods when men who have sex with men are more vulnerable to contracting HIV, including when traveling, on vacation, moving to a new city or after a break-up. Egan and his team set out to explore whether these men might be more receptive to adhering to PrEP treatment during these times.

The team followed 48 adult men from Pittsburgh or Boston who have sex with men in a pilot program to test the daily use of PrEP for 30 days that included an out-of-town vacation, with the men starting the medication seven days before the trip and continuing for at least seven days after vacation. The men were also given a brief session introducing them to the use of PrEP.

After their vacations, 94% of the men had blood concentrations protective against HIV, consistent with regular use of the medication. Almost 75% reported condomless sex during vacation, and about a third reported recreational drug use. None of the men contracted HIV during their vacation, though one of the men contracted the virus during the three-month post-vacation follow-up period when he’d had a lapse in use of PrEP associated with loss of health insurance and a move to a new city.

Additionally, 70% of the participants indicated an interest in continuing daily PrEP use long-term.

“That really stood out to us,” said senior author Kenneth Mayer, M.D., medical research director at The Fenway Institute at Fenway Health in Boston and professor of medicine at Harvard. “It shows us that introducing short-term use of PrEP before a vacation could lead to longer-term use. This presents an enticing opportunity to reduce HIV transmission.”

However, the scientists pointed out, the study included men who were motivated to enroll and did not address the likelihood of physicians prescribing PrEP for short-term use, the ease of obtaining PrEP for use only during vacations or the impact of the study’s brief counseling on the use of PrEP.

“These are all areas that our findings suggest warrant future explorations,” Egan said. “Our study tells us short-term adherence to PrEP during high-risk periods is tolerable in men who have sex with men, and that it could lead to long-term use. Now we need to determine how to make it possible in the real-world setting.”

Additional authors on this research are Ken Ho, M.D., M.P.H., and Ron Stall, Ph.D., M.P.H., of Pitt; Moe T. Drucker, B.S., and Ryan Tappin, N.P., M.P.H., of Fenway Health in Boston; Craig W. Hendrix, M.D., and Mark A. Marzinke, Ph.D., of Johns Hopkins University; Steven A. Safren, Ph.D., of Fenway Health and the University of Miami; Matthew J. Mimiaga, Sc.D., M.P.H., of Fenway Health and Brown University; Cristina Psaros, Ph.D., of Massachusetts General Hospital; and Steven Elsesser, M.D., of Fenway Health and the University of Pennsylvania.

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Health & Wellness

Notable percentage of trans men who have sex with men never got tested for HIV, bacterial and viral STIs

When considering screening for HIV and sexually transmitted infections (STIs), transgender men who have sex with men (TMSM) represent an understudied population. A study found that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs.

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When considering screening for HIV and sexually transmitted infections (STIs), transgender men who have sex with men (TMSM) represent an understudied population. A study found that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs.

In “Sociodemographic and behavioural factors associated with testing for HIV and STIs in a US nationwide sample of transgender men who have sex with men” – done by Nadav Antebi-Gruszka, Ali J. Talan, Sari L. Reisner and Jonathon Rendina, and published in BMJ Journals – researchers tried to examine HIV and STI testing prevalence among TMSM along with the factors associated with testing in a diverse sample of TMSM. They used data from a cross-sectional online convenience sample of 192 TMSM, analyzed using multivariable binary logistic regression models to examine the association between sociodemographic and behavioral factors and lifetime testing for HIV, bacterial STIs and viral STIs, as well as past year testing for HIV.

The researchers found that more than two-thirds of TMSM reported lifetime testing for HIV (71.4%), bacterial STIs (66.7%), and viral STIs (70.8%), and 60.9% had received HIV testing in the past year. Engaging in condomless anal sex with a casual partner whose HIV status is different or unknown and having fewer than two casual partners in the past six months were related to lower odds of lifetime HIV, bacterial STI, viral STI and past year HIV testing.

Being younger in age was related to lower probability of testing for HIV, bacterial STIs and viral STIs.

The domiciles of the TMSM also affected their health-seeking behaviors. In this study, those residing in the South of the US were less likely to be tested for HIV and viral STIs in their lifetime, and for HIV in the past year.

Finally, lower odds of lifetime testing for viral STIs was found among TMSM who reported no drug use in the past six months.

According to the researchers, these findings indicate that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs, though at rates only somewhat lower than among cisgender MSM despite similar patterns of risk behavior.

They recommend for “efforts to increase HIV/STI testing among TMSM, especially among those who engage in condomless anal sex.”

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People You Should Know

Living with HIV in Digos City

Meet Robin Charles O. Ramos, a person living with HIV in Digos City in Davao del Sur. There are numerous challenges there – e.g. they still have to go to Davao City for their laboratory tests, and get monthly supplies of life-saving ARVs. But they are starting to organize so PLHIVs can help each other.

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“We cannot deny the fact that there are people who will really discriminate us (people living with HIV),” said Robin Charles O. Ramos, who is based in Digos City in Davao del Sur in Mindanao, southern Philippines. “(But) think twice… before you discriminate because (everyone can be infected with) HIV.”

BI AWAKENING

Charles, 33, used to be only attracted to girls. But when he was nine years old, “I (was also) attracted to boys. I realized that I am attracted to both sexes.”

Charles’ family teased him for this. But he added that it’s not like they can prevent him from being bisexual; this “runs in the family,” he said, with other family members also LGBTQIA.

“It was somewhat difficult for me to come out,” he said. This is because he lives in a “relatively small community (where people know me).”

Digos, a 2nd class city and the capital of the province of Davao del Sur, has a population of only 169,393 people (in 2015).

But Charles eventually told others, realizing the relevance of being true/honest to oneself. “I know it (may not be easy) but… the community will (eventually) understand who and what we are.”

FINDING OUT ABOUT HIS HIV STATUS

On November 30, 2017, Charles found out he has HIV.

Prior to the diagnosis, he recalled having bad health – e.g. his cough wouldn’t go away, he had lymph nodes in his throat, he easily got tired/stressed out, and he had recurring fever. He self-medicated, “taking paracetamol” and antibiotics.

“I lost a lot of weight,” Charles recalled, “from 56 kilograms to 48 kilograms.”

At that point, his mother told him: “It’s time to rush to the hospital.”

The attending physician had Charles undergo more tests… including HIV antibody test.

The person who gave him the news about his HIV status was “actually a friend of mine.” In fact, he pre-empted the counselor from telling him the result; “I told her myself, ‘It’s positive, right?’.”

EVERYONE CAN BE INFECTED

Even before then, Charles actually worked in HIV advocacy.

So the person who gave him the news about his HIV status was “actually a friend of mine.” In fact, he pre-empted the counselor from telling him the result; “I told her myself, ‘It’s positive, right?’.”

That was also “mind conditioning” for him, he said. “I conditioned my mind that I’m positive already… it’s a way of acceptance of the matter.”

Right there and then, Charles opted to tell family members. And they had one question for him: Why him, considering he’s in HIV advocacy, and should know better?

“Anyone can be infected,” Charles said to them.

“Think twice… before you discriminate because (everyone be infected with) HIV.”

BEING OPEN ABOUT LIVING WITH HIV

If there’s one thing Charles said that’s good about being out, it’s being able to get external help as needed.

“I lose nothing by coming out,” he said. And for him, “PLHIVs need to come out… as a strategy for us to eradicate stigma and discrimination.”

At this stage in his life, “I don’t care if they talk about me. This is already here. Just accept it.”

Charles is also a teacher, and he opted to tell his supervisors and peers about his medical condition. This honesty paid off since “they support me.” His workmates always remind him to “not be stressed” and “have time to rest”.

HIV-RELATED ISSUES IN DAVAO DEL SUR

HIV screening and/or testing is, at least, accessible to the people of Digos City, said Charles. The social hygiene clinic (SHC) of the local government unit (LGU), for one, offers this; and “every time we conduct (gatherings) about HIV, there is HIV testing (given).”

It is the access to life-saving medicines (the antiretroviral treatment, or ARV) that is problematic.

“Here in Digos City, ARV is not yet available,” Charles said.

And so PLHIVs from there have to go to the Southern Philippines Medical Center (SPMC) in Davao City, which is 62.5 kilometers away (or approximately an hour of commute).

If there’s one thing Charles said that’s good about being out, it’s being able to get external help as needed.

Many of the PLHIVs from Digos City go to SPMC together, renting a van to take them to and from Davao City for their regular tests and ARV supplies.

A related issue: PLHIVs have to go every month because they are only given a month’s supply because of procurement issues. The usual practice is to give PLHIVs supply for three months. And – even if the Department of Health denies that there are issues concerning ARV supplies – at least the Digos City experience highlights the continuing difficulty with accessing life-saving medicines.

The dream for PLHIVs like Charles is for a refilling station to be established in Digos City to serve not only those living there, but also the nearby localities of Kidapawan City, Davao Occidental, et cetera.

EMPOWERING THE HIV COMMUNITY

Charles recognizes that many try to help PLHIVs, but he also thinks that empowering PLHIVs to help each other is essential.

“We have formally created a group: Bagani Southern Davao,” he said. The name was derived from the word “Bagani”, the peacekeeping force of the Manobo tribes and other indigenous groups in Mindanao. Akin to the word, “we’re warriors; we’re fighting against this illness.”

There are currently 20 active members; though, of course, not all PLHIVs in the area are members.

The dream for PLHIVs like Charles is for a refilling station to be established in Digos City to serve not only those living there, but also the nearby localities of Kidapawan City, Davao Occidental, et cetera.

To other PLHIVs in the area, Charles said he recognizes that it may take time before they can decide if they’d come out. “I respect (this) decision… But coming out as PLHIV is a way of educating people that they shouldn’t fear us, and that (having HIV) isn’t the end of our lives or the end of anything.”

As PLHIVs, he said, “we have more to offer, more to do” particularly in educating people.

And to non-PLHIVs or those who do not know their HIV status: “Know your status. Get tested. And stop discriminating people. It’s not like we wanted this to happen to us. But this is already here. We just need your support, and the respect that we want because we’re still human beings.”

“I lose nothing by coming out,” he said. And for him, “PLHIVs need to come out… as a strategy for us to eradicate stigma and discrimination.”

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HIV research over-emphasizing select populations at detriment of others – study

Medication to manage HIV is now very effective at keeping people well. But over half of people living with HIV do not take their medication as prescribed. The problem could be in the way that studies are designed in the first place – with BAME communities, women and straight men under-represented.

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Photo by Manh Nghiem from Unsplash.com

People with HIV from Black, Asian and minority ethnic (BAME) communities, women and heterosexual men are underrepresented in HIV studies. This is according to research from the University of East Anglia and Western Sydney University.

Medication to manage HIV is now very effective at keeping people well. But over half of people living with HIV do not take their medication as prescribed. But the world has yet to find solutions that are routinely used by healthcare teams to successfully support people to take their medication as prescribed – despite many studies designed to investigate the problem.

New research revealed that the problem could be in the way that studies are designed in the first place – with BAME communities, women and straight men under-represented.

The research team said that this imbalance of representation needs to be fixed, in order to design solutions that suit the needs of a diverse population and keep people with HIV living longer, healthier lives.

Lead researcher Prof Debi Bhattacharya from UEA’s School of Pharmacy said: “It’s really important that people with HIV start taking medication as soon as possible and continue taking it as prescribed for life. While medication can’t cure HIV, taking it correctly helps people live longer, healthier lives. Medication can also reduce the risk of HIV transmission.”

The research team reviewed 80 studies designed to evaluate different approaches for supporting people to take their HIV medication correctly. They found that people from ethnic minorities, women and heterosexual men were underrepresented for the country in which the study was taking place.

Prof Bhattacharya said: “We found that none of the 80 studies had a trial population that reflected the actual population of people living with HIV. For example in many cases, gay men were over-represented in studies, compared with the amount of gay men living with HIV.”

In one American study, not a single woman was included even though women represent around one in five people with HIV.

“This is a problem because we know that in several countries including America, HIV rates in men are falling more than they are for women.”

As these patient groups are being significantly underrepresented in these types of trials, their needs, beliefs and attitudes to treatment are not fully understood. This potentially leaves these populations without the support they need to live well with HIV.

“We also know that language profoundly affects the way patients understand their treatment routines – which impacts on how they engage with their disease and medication. Failure to take this into account seriously hinders people from getting the best clinical outcomes.”

Research methods must be adapted to support the wide range of people with differing needs that make up the diversity of people with a specific disease.

The researchers similarly found that none of the studies used research methods to encourage people with differing languages and culture to contribute in the ways that are needed for the research to be successful.

“This may explain why we have seen few of these solutions that are shown to work in the studies then go on to be routinely used in healthcare.”

Over the years, greater scrutiny has been noted on how research is conducted to ensure that people invited to participate in research are fully informed before they decide to participate. “But, the changes have led to new problems, such as people with limited literacy or those less fluent in the local language being excluded from studies. It is important that we continue to protect the public whilst also supporting people with differing needs to participate in research.”

According to the researchers, the guidelines for carrying out research need to recognize that research methods must be adapted to support the wide range of people with differing needs that make up the diversity of people with a specific disease.

“The guidelines also need to communicate more strongly, the importance of properly involving people for whom the research is intended to help, at the earliest possible stage of the research otherwise these health inequalities may continue.”

This research was led by the University of East Anglia in collaboration with Western Sydney University, Australia.

‘Do interventions to improve adherence to antiretroviral therapy recognise diversity? A systematic review’ is published in the journal AIDS Care.

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