News and upcoming events
Gay Men's Sex Survey 2008
The Gay Men's Sex Survey, conducted by Sigma Research, is the largest annual survey of gay and bisexual men in the world. It is completely anonymous and takes about 15 minutes to complete. The information that we gain from this research informs and motivates our work, ensuring that our efforts have the maximum impact in preventing new HIV infections. Visit www.demographix.com to complete the survey.
Small Media - what is in the bars and how to get more information about it:
Need Help?
Need Help? (5th edition, striped cover) is an update of our pocket-sized guide to
everything that's gay in London. It's a complete listing of virtually all the help lines,
websites, and support organisations across the capital. It includes contact details for
gay youth groups in several different boroughs. There is a large section on sexual health
clinics, divided up by location (so you can find the one nearest you), clinics that offer
gay-specific services and ones that offer 1-hour HIV testing. You will also find
contact details of support groups for HIV-positive men, victims of homophobic violence,
men who sell sex, and services for black and Asian men, as well as where to go for
counselling services and how to sign up for self-help workshops.
Camden Good Sexual Health Team small media resources
What do you do when you're Wasted? This is a new, mini version of Camden's
booklet about drugs, alcohol and how they affect the decisions gay
men make regarding their sexual health. A Little Bit Wasted looks at the
reasons why gay men use drugs and alcohol in the first place - and
gives practical advice on how to use them more safely or cut down. There is
information about which drugs don't mix together and why - and a section about
which HIV medications have negative interactions with recreational drugs. Wasted
includes advice for recreational drug and alcohol users on how to have safer sex
when high.
'Reasons To Be Tested' is a new mini booklet that explains why it's a good idea to
take a test and know your HIV status. It explains how, if you are HIV-positive,
your best chance of living a long and healthy life lies in knowing your status.
Once diagnosed, you will be able to get the medical, practical and emotional
help that you need.
Other small media resources for gay men.
Upcoming Courses & Workshops for gay men:
Workshops and courses in October and November are:
GMFA Courses
If you want to stop smoking then our seven session Stop Smoking course for gay men can help. Evidence shows that the support you get from a Stop Smoking course, combined with the relief from withdrawal symptoms that Nicotine Replacement Therapy gives you, makes your attempt to quit ten times more likely to succeed than if you use willpower alone.
- The next course begins 7pm Thursday 7th August for 7 weeks
- The following course begins 7pm Tuesday 26th August for 7 weeks
To book a place or for more information, click on the link above or call 020 7738 3712.
PACE Workshops
Friend or Foe - is a weekend workshop on self-esteem, exploring how you can relate to yourself in more compassionate, supportive and constructive ways and move away from being critical, nasty or destructive to yourself.
Begins 6.30pm Friday 3rd October. Continues Saturday 4 and Sunday 5 October.
Risky Business - is a weekly on-going group where you will be able to share and talk about your experience with other gay/bi men, gain insight and make changes in your life. This group is for you if you find it a challenge to maintain safer sex, if your sex life feels out of control or if you have recently been prescribed PEP or used PEP in the past.
Begins 6.30pm Tuesday 7th October and continues every Tuesday until 16th December.
The Black Connection - is a monthly group for black men who have sex with men, to meet, talk & socialise as well as explore themes that will help celebrate the diverse community, relationships and lifestyles of Black men who love men.
The third Sunday of the month, 6 till 9pm. Next date: 19th October.
TwentySomething - is a relaxed and friendly monthly social and support group for gay and bi men in their 20s enabling them to meet others, talk about issues that matter to them and have fun. Monthly events will include discussions and workshops on all aspects of gay life including sex, relationships, coming-out, self esteem and assertiveness.
The third Monday of the months from 6.15pm till 9.15pm. Next date: Monday, 20th October 2008.
Sexual Debut - is an 8 week programme which will give you an opportunity to explore with other gay/bi men what coming out really means for you. You will gain skills on how to negotiate in the gay scene and build your confidence around sex & relationships.
Begins 6.30pm Thursday 30th October and continues for eight weeks.
Out of Control? - is a weekend for gay men who are unhappy about the amount or kind of sex they are having.
Begins 6.30pm Friday 7 November. Continues Saturday 8 and Sunday 9 November.
To book a place or for more information call 020 7700 1323.
THT Courses
Mind Your Backs Guys! All you'll ever need to know about your arse and his
Ever been curious about prostates, the male G-spot, buttock exercising or douching? Whether you want to learn more about how to enjoy anal sex or have questions about the health of your posterior, this group is for you.
Thursday 16th October and every fourth Thursday of the month from 6pm to 9pm.
Book a place on 'Mind Your Backs Guys!'
Positively drug fucked
Are you HIV positive and been so 'out of it' that you've forgotten to take your pills or not taken them like you should? Would you like to know more about the impact that the recreational drugs you are taking are having on the virus. This group will guide you through the drugs that are out there, the impact that they can have on you, your meds, the virus and give you the information to help you make the right choice.
Book a place on 'Positively drug fucked'
How not to pick up
Have you ever found yourself with more than a phone number as a memory of that night of fun? Many of us will get a sexually transmitted infection at some time, even if we have safe sex or sex with only a few men. "How not to pick up" is a gay men's group which will guide you through what's out there, how to avoid it and what to do if you do "pick up".
Thursday 23rd October and every fourth Thursday of the month from 6pm to 9pm.
Book a place on 'How not to pick up'
Sex Addicts Course
If you see yourself as a sex addict or a sexual compulsive and feel that
your sexual behaviours are having an overwhelming and negative impact
on your life, then we may be able to help. In July, Terrence Higgins Trust
will commence a weekly group programme for gay men who feel that their
relationship with sex is somehow out of control.
Eight week programme begins Thursday 23rd October 2008.
For more information, venue details or to book an assessment, call 0207 812 1773.
Other courses
Recently Diagnosed Course - held four times a year, this is a structured course open to anyone newly diagnosed in London who would like to be better informed.
To access this course, call Simon Johnson on 020 7812 1777 during office hours from Monday to Friday.
Living with HIV in Tower Hamlets - this course is for you if you want to know more about sex, intimacy and status disclosure, dealing with medication, coping with frustration, fatigue and isolation, and moving forward with your life.
Whether you are recently diagnosed or have been living with HIV/AIDS for some time you will find this course helpful and fun!
For more information on the next available course, please call Simon on 020 8694 9988 ext 208 or email epp@thepositiveplace.org.uk
Support Groups
The Midweek Group
Thanks to sponsorship from The Eddie Surman Trust (020 7738 6893) and the hospitality of South Central pub in Vauxhall, 'The Midweek Group', formerly supported by the UKC, continues to meet, socialise and have speakers on a regular basis (Tuesdays 6 - 9pm). Anyone interested in joining the group can come along on a Tuesday to enquire about membership.
Support groups for gay men from THT
Newly Diagnosed Gay Men's Group which meets twice a month at a Soho location, a support group for gay men diagnosed within the last year in London.
Gay Men's HIV Support Group which meets each Monday evening at a Soho location, for longer term diagnosed gay men in London.
Negative Partners Group which meets the last Thursday of the month at THT on Gray's Inn Road, open to the negative partner in a serodiscordant relationship.
In the autumn THT will be starting a Sex Addiction Support Group facilitated by their new addictions counsellor.
To access any of the above support groups, please call Simon Johnson on 020 7812 1777 during office hours from Monday to Friday.
Helplines
London Lesbian & Gay Switchboard - 020 7837 7324
LLGS normal opening helpline hours are 10am to 11pm daily.
THT Gay Men's Sexual Health Helpline - 020 7998 4161
This is a new helpline to give, information, advice and support about sexual health to gay men in London, whether they have HIV or not.
Broken Rainbow
The Broken Rainbow LGBT Domestic Violence Helpline is now open during the hours outlined below. The Helpline has recently partnered with London Lesbian & Gay Switchboard to provide an improved service to the Lesbian Gay Bisexual and Transgender community specifically. The helpline is staffed by LGBT people and offers a confidential service, across the UK, and supports LGBT individuals, family, and friends experiencing domestic violence. They also take calls from agencies seeking information and advice.
The Broken Rainbow LGBT Domestic Violence Helpline is open on: Mondays and Thursdays from 2pm to 8pm; Wednesdays 10am till 1pm. The Helpline number is 08452 60 44 60.
Further information is also available via their website: www.broken-rainbow.org.uk.
FS magazine
The summer 2008 issue of FS is now available online and in bars and clubs across
London. You can download the pdf of the current issue by clicking on the image on the
right. Download pdf's of previous issues of FS from the
website.
Issue magazine
The latest edition of 'Issue', the magazine of HIV and sexual health sector development,
has been published. Copies can be obtained by emailing Andie Dyer at
andie.dyer@tht.org.uk.
U+ magazine
Terrence Higgins Trust have launched a new magazine for gay men with HIV. U+ presents
health information in an easy to read magazine format, with a mix of articles, interviews
and quizzes, as well as a problem page.
Each issue focuses on a particular theme. Issue three (out now) is about sex for gay men with HIV – dealing with HIV treatment, who's who at your clinic, other ways to look after your body and mind. Click on the image to download a copy from this website.
If you distribute health promotion resources to gay venues in your area, we would particularly encourage you to help us make U+ available on the commercial gay scene.
To order free copies for your organisation, please contact healthpromotion@tht.org.ukMass Media - what is in the press and how to get more information about it:
GMFA's Arse Facts Campaign:
It's tricky getting to know your arse; it's not something you look at everyday.
But whether you're a top, bottom or flip both ways, there are a few essential
facts that you should know to help keep you and your partners safe and healthy.
After reading the facts, why not
enter The Arse Factor for a chance to
win £100 of underwear or swimwear.
For more information contact rob.dawson@gmfa.org.uk
THT's Biology of Transmission Pt 2:
On the 17th December THT launches the new CHAPS national campaign
'Biology of Transmission Pt 2' which aims to alert gay men to the added risk of
using nitrite inhalents (commonly known as 'poppers') when being the receptive
partner during UAI.
The programme of work will be lead by a mass media campaign in gay publications from 19/12 until mid-February and will be supported by a website www.chapsonline.org.uk/biology; a new booklet 'Ready for action' which details how HIV is passed and how to reduce the risk; Exposed! 11, and a CHAPS Poppers Sector Summary Report.
For more information on the campaign and materials contact campbell.parker@tht.org.uk
Counselling waiting times & information:
New Counselling Service from The GMI Partnership
The new GMI Partnership Counselling Service offers talking therapies which are designed to assist men who have sex with men:
- identify their risk factors for unsafe sex
- reflect on the issues and challenges in practising safer sex
- set goals and plan and implement strategies for reducing or eliminating risk.
This service is open to all men who have sex with men regardless of HIV status who have concerns with adopting or maintaining safer sex and HIV risk reduction behaviour. All men entering the Service will be offered a confidential assessment, and through a process of discussion will be able to identify the most appropriate talking therapy for them. These include:
- Cognitive Behavioural Therapy
- Peer mentoring
- Sexual health counselling
For further information or to make an assessment appointment please call 020 8305 5002 or email info@gmipartnership.org.uk.
Healthy Gay Living Counselling @ THT
THT now have a dedicated substance misuse and addictions counsellor within the well-being team offering a One-2-One service to gay and bisexual men. It may well be that you do not want to talk to friends or family about your concerns so if you are worried or anxious about the drugs you take, then this counselling resource may be able to help. So if your relationship with drugs is having a negative impact on other areas of your life, feels out of control or you are using drugs in combination and don't know what the consequences might be, feel free to call us with your concerns. You can arrange an assessment by calling the Wellbeing Service on 020 7812 1777 and speak with either Simon or Jason.
Also appointed is a specialist young person's counsellor working with young men living, working or studying in the borough of Southwark. To access this service you need to be male, aged between 16 and 24 and either gay, bisexual or questioning your sexuality. There is currently no waiting time for this service.
Languages we can provided counselling in are: English, French, German, Portuguese, Spanish, Italian, Yoruba, Luganda, Shona. Counselling is available for couples and individuals at sites across London, with appointments available in the evenings or on Saturdays, as well as during the day.
To book an appointment call Simon Johnson on 020 7812 1777 - Office hours are 9.30am to 5.30pm
Volunteers needed
The Gay Men's Interactions Partnership has exciting new opportunities for
volunteer peer mentors, counsellors and health trainers. For more information
click on the image to view the full advert, call 020 8583 2404 or email
info@gmipartnership.org.uk
Sector Information
Resources from THT
Healthy Respect
The Healthy Respect web pages give advice and information for people who have experienced problems with their healthcare because of their HIV status. Problems with GPs, dentists and other healthcare professionals are highlighted and solutions are offered. For more information, visit www.tht.org.uk/healthyrespect
GPs and Gay Men (CHAPS)
This programme of work has launched with the aim of providing gay and bisexual men with information which will enable them to have a better understanding of how the healthcare system works and why being gay or bisexual is important to their health care.
The programme includes a website for gay men including issues such as how the health
system works, what it can do and how being gay might effect your health and healthcare.
This can be found at
http://gpsandgaymen.chapsonline.org.uk
The website also contain a health professionals’ section containing extra
resources to ensure their services are meeting the needs of their gay and bisexual
patients.
A booklet accompanying this site, ‘GP treatment for gay and bisexual men’ is also available by contacting James Glavin at james.glavin@tht.org.uk or can be ordered individually by calling THT Direct 0845 12 21 200.
Your next steps
This booklet is for you if you’ve just found out you have HIV. You might also find it helpful if you’ve known for a while, but have not wanted to think about it much until now.
The booklet covers things that we often want to know about at this time.
There’s straightforward information about what HIV is and how we can
look after our health. The booklet talks about having sex when you have HIV,
and whether or not it’s a good idea to share your news with other people.
‘Your next steps’ is available by contacting James Glavin at james.glavin@tht.org.uk or can be ordered individually by calling THT Direct 0845 12 21 200.
Advice services for Homeless LGBT people across London are saved and will expand
Stonewall Housing is delighted to announce that its vital advice service for
LGBT Londoners has been secured, due to new funding from London Councils. This
means that lesbian, gay, bisexual and transgender people who are homeless or
experiencing housing crisis will be able to access specialist, expert advice
from Stonewall Housing until 2012.
Anyone who is homeless or has a housing problem and needs advice can call the advice line: 020 7359 5767. www.stonewallhousing.org.
Other Services or events of interest to gay men in London.
Living Well
Living Well is an NHS funded programme and is one of the core healthcare initiatives being offered to people living with HIV across London. Living Well provides a wide range of options that are intended to promote long-term life skills, encourage the development of a supportive social community and empower participants with the ability to self manage their condition and work in partnership with their health care professionals.
Options provided are:
Positive Self Management Programme (PSMP)
One of the first steps for those who join Living Well is the Positive Self-Management Programme; better known as the PSMP. The PSMP is run by trained facilitators, some of whom are living with HIV themselves, and consists of seven weekly sessions of two and a half hours each and an optional residential weekend. Some of the areas covered include:
- Goal setting
- Action planning
- Problem solving
- Coping Skills
- Support and information
- Planning for the future
The PSMP is delivered in a supportive group environment. Through discussion and sharing of information participants are encouraged to attain new skills and direction to help them make better informed decision about managing their condition.
The PSMP allows participants to meet other people facing similar concerns and challenges, helping them to overcome isolation and build a supportive social network.
Non-residential Weekend
Participants who have completed the PSMP are invited to attend an optional residential weekend. This is an opportunity to engage in workshops that will encourage a deeper experience and exploration of some of the issues and topics raised throughout the seven week programme
Facilitator Training
Training is offered to participants who have completed the PSMP and wish to become tutors, delivering the PSMP to their peers. Training is delivered under assessed conditions under license of Stanford University.
Life-Coaching
Twelve one-to-one sessions are offered with a qualified coaching psychologist. Coaching is suitable for clients who are keen to work strategically towards achieving future goals.
Counselling
Hour long sessions with a Living Well counsellor. These sessions are suitable for clients who are dealing with emotional issues which are usually related to their HIV status.
Positive East
The Gay Men's Team at Positive East offers a comprehensive range of services for gay men and men who have sex with men who are positive, negative or untested, who live or work in East London. For details visit www.gaymenswellbeing.com, email us at gaymen@positiveeast.org.uk or telephone Positive East on 020 7791 2855.
Himat, a group for South Asian gay, bisexual and men who have sex with men exploring issues of sexuality, culture, religion and race. For many South Asian gay men in London, facing up to being different can be full of unique problems. Being a minority within a minority can create a strong sense of isolation from other gay men. For details on Himat visit www.gaymenswellbeing.com or call on 020 7791 2855.
Positive Life is an activities group for HIV positive gay and bisexual men. The groups main aims are to offer a non-scene space for gay and bisexual men to meet and discuss topics of interest; to make friends with other positive gay men; be able to share experiences and where they can give and/or receive support, as well as an opportunity to learn new skills. For details on Positive Life go to www.gaymenswellbeing.com email positivelife@positiveeast.co.uk or call on 020 7791 2855
Signpost, a confidential telephone helpline for men who have sex with men provides basic information and guidance on sexual health, HIV/STI's as well as accessing services and groups across east London. Signpost operates every Tuesday and Thursday from 6.30 to 8.30pm on 020 7790 5795. For details on Signpost visit www.gaymenswellbeing.com
Interesting articles and news from around the world:
PrEP could be cost-effective and avert infections in high-risk MSM: model
A PrEP programme targeting 25% of the highest-risk gay and other men who have sex with men in New York City could potentially prevent between 4% and 23% of the new infections predicted to occur in the next five years, according to a modelling study reported in the September 12 th issue of AIDS. Over half of these infections would be prevented in men who were not themselves taking PrEP, but due to reduced overall HIV prevalence. The cost was estimated at US $31,970 per quality-adjusted year of life saved.
Pre-exposure prophylaxis ( PrEP) is a potential prevention method in which antiretroviral drugs are taken before a possible HIV exposure, to reduce the risk of infection. One approach being considered is the ongoing, daily use of such prophylaxis for people with frequent high-risk exposures.
Until clinical studies (currently underway) provide the answers, questions remain as to how effective – and how cost-effective – PrEP programmes might prove. One mathematical modelling study presented at the 16th International AIDS Conference found that PrEP would be cost-effective as long as it proved more than 50% effective.
In this study, another group of researchers used a mathematical model to simulate the possible effects of a five-year PrEP distribution programme among gay and other men who have sex with men (MSM) in New York City whose sexual activity puts them at risk of HIV. The objectives were to predict the number of HIV infections that could be prevented, and the cost-effectiveness of the programme compared with current prevention practices.
Key assumptions
The model was based on published epidemiologic data for New York City, and assumed a PrEP programme targeted to the "highest-risk" MSM – 30% of the total MSM population. The price was fixed at US $31 daily – the average US wholesale price of FTC/ tenofovir ( Truvada, the drugs currently considered the best candidates for PrEP). To allow for uncertainties in estimates, several key parameters were each assigned a range of different values: rate of adherence, 33%, 50%, or 95%; percentage of high-risk MSM reached by the programme (population coverage), 2.5% (1500 high-risk MSM covered) or 25% (15000 covered); and PrEP efficacy, 0%, 30%, 50% or 70%. The way in which efficacy related to other parameters (adherence and levels of viral exposure) was also calculated in several ways.
Working out of these different possible estimates resulted in a total of 36 hypothetical scenarios. Furthermore, within each of these 36 scenarios, epidemiological factors (including numbers of new sexual partners and probability of HIV transmission) were varied 200 times. All in all, a total of 7200 simulations were run, each with a different configuration of parameters.
Results
Based on current incidence rates, 19,510 new HIV infections are expected to occur among all MSM in New York City over the course of the next five years,
By making PrEP available to 25% of the highest-risk MSM in the city, the simulations predicted that between 4% (780) and 23% (4510) of these infections could be prevented. More than half of these prevented infections would be among those not accessing PrEP directly themselves, but would be due to reduced HIV prevalence in the community due to the PrEP programme.
The "base-case" scenario made the following assumptions: 25% of high-risk MSM (15,000) were reached; 50% of the men in the programme were fully adherent; PrEP was 50% effective at 100% adherence and 0% effective otherwise. Under these assumptions, 1710 new HIV infections (8.7% of those expected) would be averted (90% confidence interval [CI], 306 to 2947). Seven hundred of these averted infections were directly due to PrEP use, and 1010 secondary cases due to reduced prevalence. The incremental cost was US$ 31,970 per quality-adjusted years of life [QALY] saved.
Varying the parameter models resulted in a worst-case scenario of zero benefit (no new infections averted), and a best case of 23%, or 4510 (90% CI, 3144 to 6129). Across all assumptions, PrEP was cost-effective 75% of the time, using a threshold of US $50,000 per QALY saved.
Coverage rate appeared to be the most critical variable. Estimated reductions of 4% to 23% were seen at coverage rates of 25% of high-risk MSM; when only 2.5% were covered, not enough new infections were averted to justify the intervention.
The report concluded that, although subject to many still largely unknown variables, a programme of "HIV chemoprophylaxis [ PrEP] among high-risk men who have sex with men in a major US city could prevent a significant number of HIV infections and be cost effective… over a broad range of … variables." They believe that these findings "should give strong impetus to the ongoing chemoprophylaxis trials as well as to research on potential program implementation."
Reference:
Desai K et al. Modeling the impact of HIV chemoprophylaxis strategies among men who have sex with men in the United States: HIV infections prevented and cost-effectiveness. AIDS 2008 ;22:1829–1839.
Nearly one in three UK HIV patients has considered suicide in the previous week
A UK study of HIV patients at four clinics in London and one in Brighton has found that 31% reported having had suicidal thoughts over the previous week.
The study, published in the journal AIDS , found that heterosexual men, people of black ethnicity and people who had not disclosed their status to anyone were about twice as likely to have suicidal thoughts as other groups.
Other strong predictors of suicidal ideation were being unemployed, being single, and having stopped HIV treatment, though these factors lost significance in multivariate analysis.
Suicidal thoughts were also associated with poor treatment adherence and with having poorer physical and/or mental health, but were not associated with age, being on treatment, time on treatment, type of treatment or viral load.
Since 1990, the authors note, 271 or nearly 2% of the approximately 14,000 HIV positive people who have died in the UK have taken their own lives, and the proportion of deaths due to suicide has increased in the period since effective HIV treatment became available. However, there have not been many studies of suicidality since the advent of combination HIV treatment, and studies have also left it unclear as to whether HIV infection was independently associated with suicidal thoughts or whether they were simply more common in the kinds of people more vulnerable to HIV.
The UK study, led by Professor Lorraine Sherr of Royal Free and University College Medical School, asked all 903 eligible patients attending the five clinics in a three-month period in 2005 and 2006 to fill in a confidential questionnaire asking then whether they had experienced suicidal thoughts over the previous week, and if so how frequently.
It also established demographic information and asked about sexual behaviour and relationship status, treatment optimism and whether patients had disclosed their HIV status to anyone, treatment status and adherence to treatment, symptoms of physical and mental ill-health, and general quality of life. There was a high response rate, with 86% of eligible patients filling in the questionnaire.
Two-thirds of the patient group were gay men, a quarter women, and 10% heterosexual men. Just over half had been born in the UK; 25% described themselves as black and 8% Asian or other, with the remainder describing themselves as white. Twenty-one per cent had never taken antiretroviral therapy, 66% were currently taking such treatment and 13% had anti-HIV drugs but had stopped. Fifty-three per cent were employed.
Of the 31% who had had suicidal thoughts over the last week, just over 10% said the thoughts were “frequent” and just over 5% ‘constant’. The rest said they were occasional.
The raw data show that the strongest predictors of suicidality were, in this order, being in poor physical or mental heath; being unemployed; being poorly adherent; not being in a stable relationship; not having disclosed HIV status to anyone outside the clinic; being of black ethnicity; and being a heterosexual man.
Factors not associated with suicide included age, having had unsafe sex, number of sex partners, pessimism about treatment or being infectious, and type of treatment. However suicidality was significantly higher in those who had stopped treatment (43%), and there was the same rate of suicidal ideation in those who were poorly adherent.
After multivariate analysis, sexuality, ethnicity, disclosure and state of physical and mental health remained the only independent predictors of suicidality. Heterosexual men nearly twice as likely as gay men and 2.5 times more likely than women to feel suicidal; black people nearly twice as likely as white (most heterosexual men were black); and people in poor mental health, unsurprisingly, 2.3 times more likely. The association between suicidality and being a heterosexual man was even stronger in the patients on HIV treatment.
Since 1990, the authors note, 271 or nearly 2% of the approximately 14,000 HIV positive people who have died in the UK have taken their own lives, and the proportion of deaths due to suicide has increased in the period since effective HIV treatment became available. However, there have not been many studies of suicidality since the advent of combination HIV treatment, and studies have also left it unclear as to whether HIV infection was independently associated with suicidal thoughts or whether they were simply more common in the kinds of people more vulnerable to HIV.
The present study appears to back the idea that HIV infection is an independent psychological stressor in its own right. The authors point out that the 31% rate of suicidal thinking is more than twice as high as that observed in gay men (13%), a group known for high suicide rates. And the fact that 45% of heterosexual men recorded suicidal thinking in the present study, as opposed to 30% of gay men, would point to HIV infection and related factors such as stigma and shame, poor health and health pessimism, and what the authors call “the burden of secrecy and lack of community and social support” as being the most significant influences on suicidal thinking.
Reference
Sherr L et al. Suicidal ideation in UK HIV clinic attenders. AIDS 22(13):1651-1658. 2008.
Black men living in England have a three times higher risk of prostate cancer than white men, figures show.
They also tend to be diagnosed five years younger, a study of all cases in London and Bristol found.
The results cannot be explained by access to diagnostic tests, awareness of the condition or screening, the British Journal of Cancer reported.
Cancer charities said the finding may lead to better care for men at higher risk of the disease.
Researchers at the University of Bristol said the US had already reported a higher rate of prostate cancer in black men.
“There's very few known risk factors for prostate cancer but it's starting to look like being of black race is a risk factor,” Dr Chris Metcalfe
In the UK study, it was initially unclear whether there was a "genuinely" higher rate of prostate cancer in these groups or whether they were more likely to be diagnosed.
But when they looked in detail at hospital records they found black and white men had similar levels of knowledge about prostate cancer, similar symptoms and similar delays before they went to their GP.
However, there was some evidence that black men were more likely to have had a prostate specific antigen (PSA) test before they had any symptoms.
Susceptibility
On why black men could be being diagnosed earlier, the researchers said prostate cancer at a younger age was more likely to be due to greater biological susceptibility to the disease.
The researchers are now doing further work to see if there are any differences in survival between the two groups.
Studies looking at whether PSA should be used as a routine screening test are also being done and it may be that it is recommended for some high risk groups but not everyone.
Study leader Dr Chris Metcalfe said this was the first evidence from the UK on differences between black and white men in rates of prostate cancer.
"One of the possibilities based on anecdote was that black men may delay presentation - so the cancer gets to a later stage.
"If anything the evidence showed black men were presenting sooner."
He added: " There's very few known risk factors for prostate cancer but it's starting to look like being of black race is a risk factor."
Dr Joanna Peak, science information officer at Cancer Research UK, said prostate cancer was the most common cancer in UK men.
"The study indicates that there is a true biological difference between ethnic groups and this knowledge could potentially lead to improved care for men at higher risk of developing prostate cancer."
Anna Jewell, from The Prostate Cancer Charity, said: "We would encourage all men to visit their GP if they are experiencing any possible symptoms of prostate cancer such as problems when urinating.
"This strongly demonstrates the need for continuing work to raise awareness of the higher risk of prostate cancer in black men.
"We would like to see further research investigating whether there are any differences in access to treatment or care for prostate cancer between black and white men to help us understand how we can meet the needs of those most at risk from the disease."
A new day for health in South Africa: Manto is replaced as health minister by TAC supporter
Activists and health workers in South Africa celebrated outside the Cape Town parliament building last night after the news that Dr Manto Tshabalala-Msimang has been replaced as South Africa’s Minister of Health by Barbara Hogan, one of the few African National Congress (ANC) Members of Parliament who spoke out openly against AIDS denialism in former president Thabo Mbeki’s government.
Barbara Hogan supported the Treatment Action Campaign’s (TAC) early efforts to get the government to provide antiretroviral therapy (ART) in the public health system.
In addition, Dr Molefi Sefularo was appointed as the Deputy Minister of Health. As MEC of the Northwest Province, Dr Sefularo supported the roll-out of PMTCT and ART and helped write the National HIV and AIDS and STI Strategic Plan for South Africa, 2007-2011.
“We believe that the period of politically supported AIDS denialism has ended with the appointment of the Minister of Health,” a TAC press release declared.
The change of government in South Africa
The cabinet changes were announced yesterday, after the newly appointed South African President Kgalema Motlanthe was sworn in to replace Thabo Mbeki ,who was recalled by the ANC last weekend after a prolonged power struggle with ANC party President, and former Deputy President Jacob Zuma.
President Motlanthe, is a well-respected veteran of the anti-apartheid struggle who until recently has kept out of the spot light. Seen as belonging to neither camp within the divided ANC, he was selected as a consensus candidate to lead the country, at least until elections next year, when Zuma is expected to run for President.
Already being seen as a bridge builder, President Motlanthe appointed a mix of Zuma and Mbeki supporters into government, as well as other respected politicians who have remained above the fray. Dr Tshabalala-Msimang, a staunch Mbeki ally, will actually remain in government, occupying President Motlanthe’s former position as Minister in the Presidency. Though this is something of a promotion, it may not be a long-lasting one.
What is important is that Dr Tshabalala-Msimang has effectively been transitioned out of the Health Department.
The inglorious career of Dr Tshabalala-Msimang
During Dr Tshabalala-Msimang’s tenure as Minister of Health over two million South Africans died of HIV.
Sometimes called Dr Beetroot, for promoting a diet of beets, African potatoes, garlic and lemon as a remedy for people with HIV, she initially resisted the roll-out of treatment to prevent mother-to-child transmission (PMTCT) and of ART in the country. Instead, she supported the right of AIDS denialists such as Dr Matthias Rath’s to sell high-dose vitamin ‘cures’ without scientific evidence of benefit.
Even after the government moved to begin introducing appropriate HIV care through the public sector (partly as the result of legal action by the AIDS Law Project and TAC), she has been accused of trying to stall it.
South Africa’s current HIV programme got underway in earnest while she was on a leave of absence to have a liver transplant. It was during this period, while the Deputy Minister of Health Nozizwe Madlala-Routledge was in charge of the Department, that the National Strategic Plan was drafted. When the Minister came back to duty, they are reported to have clashed, and Dr Tshabalala-Msimang declined to deliver an invited address at a national AIDS conference because she reportedly felt that the Deputy Minister had a more prominent position in the conference programme. Shortly afterward, Mbeki fired the Deputy Minister. Yesterday, however, in an interesting turn of fortune, Madlala-Routledge was elected the new Deputy Speaker of the National Assembly.
Infighting within the department has been typical of the former administration’s management style and there are many reports that morale in the department of health is extremely low.
Treatment activists have long called for the Minister’s removal. At the first South African TB conference in July this year, activists conducted a silent protest during a plenary talk by Dr Tshabalala-Msimang, holding up signs saying that “ South Africa needs real leadership in the fight against TB and HIV.”
The new Minister
Minister Hogan does not come from a health background. She too is a veteran of the anti-apartheid struggle, joining the ANC after the 1976 riots. She was arrested for treason by the apartheid government, tortured and imprisoned for eight years (with one year in solitary confinement).
Since release, she has been deeply involved in the ANC, and served for a time in Mbeki’s government as Finance Portfolio Chairperson, until she was dismissed by Mbeki in part for her stand on HIV/AIDS (according to the TAC press release).
But she has continued to play a role in the fight against HIV, serving on the board of the Amandla AIDS Fund (AAF) established in 2003 with a $2.5 million donation from Carlos and Deborah Santana. AAF provides ART, care, treatment and prevention services to people and children with HIV. Serving with her on the board are Archbishop Desmond Tutu, TAC’s Zachie Achmat and Luyanda Ngonyama, Head of the AIDS Law Project Mark Heywood, Dr Jerry Coovadia, and Dr Fareed Abdullah.
In an interview with News24.com, she said the biggest challenge for the Department of Health “is HIV/AIDS and all the strains that it places on the health system. I would thoroughly endorse the roll-out of antiretrovirals and any way we can accelerate that, the better.”
Minister Hogan said she welcome’s the opportunity to work with TAC. “I'm not saying we will always agree but I've always had a good relationship with the TAC and NGOs involved in that sector and I think you need to mobilise every possible sector of society at the moment, from the private sector to the NGO sector to the government sector, to improve our health services.”
TAC joyous
For their part, TAC is clearly eager to work with Minister Hogan. In fact, about 50 of the activists serenaded her outside her flat in Cape Town’s City Bowl last night.
According to an report in the Star, she came down to greet the activists. Fatima Hassan of the AIDS Law Project hugged her and announced that it was “the happiest day of her life.” (Also see this report).
But TAC acknowledges there will be tremendous challenges ahead.
“Hogan's biggest challenges will be to meet the treatment and prevention targets of the HIV/AIDS National Strategic Plan, integrate TB and HIV treatment, develop a feasible human resources plan for health workers and undo the considerable legacy of AIDS denialism left by her predecessor. The TAC will do all that it can to assist her and the Department of Health to meet these challenges.”
Fear and stigma creating hepatitis C transmission risk for HIV-positive gay men
Stigma is contributing to the sexual transmission of hepatitis C virus amongst HIV-positive gay men, a small qualitative study published in the journal Culture, Health and Sexuality suggests. The study revealed that the fear and stigma surrounding hepatitis C means that gay men are engaging in sexual activities with a high risk of hepatitis C transmission and are reluctant to disclose or discuss hepatitis C infection.
The investigator suggests that efforts should be made to counter the stigma that surrounds hepatitis C amongst gay men, and to provide targeted information about the risks of sexual transmission of hepatitis C to gay men with high risk sexual behaviours.
Outbreaks of sexually transmitted hepatitis C have been reported amongst HIV-positive gay men in the UK and across Europe. Sexual behaviours linked with the sexual transmission of hepatitis C in this population are fisting, group sex and unprotected anal sex.
Significant numbers of HIV-positive gay men select sexual partners who are also HIV-positive, a practice called “serosorting.” Although this can avoid the risk of infecting a partner with HIV, it can involve a risk of other sexually transmitted infection, including hepatitis C.
Both HIV and hepatitis C are stigmatised illnesses, arising from the potentially life-threatening nature of the infections and their association with lifestlyes that are often perceived as “deviant.”
Earlier research suggests that stigma can affect the willingness of individuals with HIV or hepatitis C to disclose their infection.
Dr Gareth Owen therefore designed a pilot study to determine the emotional experiences of stigma of HIV-positive men who were either coinfected with hepatitis C or had received successful treatment for the infection.
Six in-depth interviews were conducted in London with men aged 32 – 43. All the men had risk factors for the sexual transmission of hepatitis C, including fisting, unprotected anal intercourse and group sex. These activities often occurred within the context of private sex parties where recreational drugs were consumed. Serosorting was reported by all six individuals.
All the men attributed their hepatitis C infection to fisting, although this activity had occurred within a context of other activities that potentially involve a risk of hepatitis C transmission, including group sex, and the sharing of lubricant, sex toys and tubes to snort recreational drugs.
“Feeling” stigmatised because of hepatitis C was common amongst the six men. One individual reported that these feelings were often worse than the physical effects of the infection: “I think how it makes you feel is worse than the actual thing itself…The fear of rejection, the fear of the stigma and all that is actually more toxic than the disease itself.”
The study participants said that fear was the most important factor leading to the stigmatising of hepatitis C. This fear was attributed to a lack of knowledge about hepatitis C, fear of contagion, fear that hepatitis C would complicate existing HIV infection, fear of the impact of hepatitis C on lifestyle behaviours such as drug and alcohol use, fear of hepatitis C treatment, fear of rejection (particularly sexual rejection), and fear of death.
“I think that hep C is the big new white elephant in the room”, said one participant, “I think that gay men are afraid of hep C and I think that’s because they don’t seem to know much about it, except maybe it kills you.”
One man told of his sexual rejection because of his hepatitis C infection: “the guy who rejected me had heard about the implications of coinfection. It’s very bad news because you have to stop drinking and taking drugs.”
Diagnosis with hepatitis C was associated with shame and guilt, adding to its stigma. One individual told the investigator: “I felt grubby. I felt scanky. I felt isolated. I felt lonely…it’s the shame: the shame, secrecy, stigma and everything else.”
A diagnosis of hepatitis C was perceived as excluding men from the “cameraderie of just being HIV-positive.” This was illustrated by the comments of one of the study’s participants: “Hep C is not yet owned by the gay community like HIV, and if it isn’t owned, then it is outside and more stigmatised…Even within the gay community, and the HIV community too, it has created a ‘them’ and ‘us’ type situation.”
Stigma meant that men were not discussing hepatitis C with their sexual partners or disclosing their infection. One man said that HIV was not considered a “such a big deal” for HIV-positive men engaging in serosorting behaviours. However, “this hep C thing is a big issue. People are scared of it but nobody is talking about it.”
Another individual said, “I’ve never had anyone disclose their hep C to me yet in a sexual situation.”
There was also confusion about hepatitis C, with some men reporting that men in their sexual milieu were confusing the infection with hepatitis B.
Several of the men indicated that stigma was silencing discussion of hepatitis C amongst HIV-positive men with a high risk of sexual exposure to the virus. “Stigma silences things and that allows more stigma to build in that silence”, said one individual, “but you can understand why people have to remain silent because the stigma is there in the first place.”
Although the investigator acknowledges that the small size of his sample is a limitation of his study, he believes it “adds depth” to the evidence showing that HIV-positive gay men require health promotion information about hepatitis C.
Based upon his research he proposes a model where the fear of hepatitis C causes hepatitis C to be stigmatised by HIV-positive gay men. This fear leads to sexual rejection should hepatitis C be disclosed, with this sexual rejection leading to shame and more fear, which in turn leads to silence and non-disclosure. “This creates transmission risk in situations where HIV-positive men have serosorted and to engage in unprotected sexual practices.”
Dr Owen concludes that more needs to be done to counter the stigma surrounding hepatitis C amongst gay men and that HIV-positive men should receive targeted information about the risks of hepatitis C transmission from fisting and other sex practices that can cause mucosal bleeding.
Reference
G. Owen. An ‘elephant in the room’? Stigma and hepatitis transmission among HIV-positive ‘serosorting’ gay men. Culture, Health and Sexuality 10: 601 – 610, 2008.
UNITED KINGDOM: GPs 'Can't Read Hepatitis C Results'
Jane Kirby Belfast Telegraph (08.12.08) - Wednesday, August 20, 2008
A recently released poll found that while nine out of 10 UK general practitioners routinely administered hepatitis C tests, 38 percent were unable to read the results correctly, and 32 percent did not actively follow up with patients testing positive for the virus. More than two-thirds of the GPs, 77 percent, did not consider infectious diseases to be a major public health threat.
The survey of 200 physicians was conducted by ICM Healthcare for the Hepatitis C Trust, with funding from the pharmaceutical firm Roche. "These results are startling," said Dr. Peter Williams, a GP from East Sussex. "If we diagnose people with hepatitis C, we can treat and cure them. If we don't, very many of them are going to die."
"GPs must take some responsibility to ensure patients with hepatitis C are not left undiagnosed," said Charles Gore, the trust's chief executive. "More must be done to equip GPs with the right information so they can correctly identify those who should be offered a hepatitis C test and interpret any result correctly."
"GPs represent the frontline interface between medicine and the public. They are in the perfect position to change our appallingly low hepatitis C diagnosis rate," Williams said.
Evidence to support belief in transmission of hepatitis C by sharing drug sniffing equipment
Hepatitis C can be detected in the nasal passage, and in straws which are inserted in the nose, report researchers in the October 1 st edition of Clinical Infectious Diseases. Their findings support the hypothesis that hepatitis C can be transmitted by sharing straws or banknotes which are used to snort drugs.
The theory of hepatitis C transmission through this route is that frequent or long-term sniffing or snorting of drugs such as cocaine can cause damage and bleeding in the nasal passage. Straws or banknotes that are inserted in the nose could come into contact with hepatitis C infected blood or mucus, which may then be transmitted to someone else sharing the same straw.
In recent years there have been numerous outbreaks of hepatitis C among HIV-positive gay men in Europe. Whilst there is a growing body of evidence that infection is associated with sexual practices including fisting, use of sex toys and group sex, some studies have also suggested that sniffing drugs may contribute to transmission.
At the same time, in many countries up to a quarter of hepatitis C infections remain unexplained, with individuals reporting no risky practices such as use of shared drug injection equipment.
And a number of epidemiological studies in largely HIV-negative populations (typically, blood donors or street drug users who do not inject) have found an association between snorting drugs and hepatitis C infection. Nonetheless not all studies have reported this finding, and there have been some criticisms of the methodological quality of these studies.
However, until now no study has examined the virological plausibility of the belief that sharing equipment to sniff drugs may contribute to hepatitis transmission. Investigators in New York therefore recruited 38 adults who snort drugs and have hepatitis C at a neighbourhood health clinic.
Tests conducted included:
- Nasal swabs to test for the presence of hepatitis C and blood in the nasal passage
- Each subject was asked to inhale air through plastic straws, which were then tested for hepatitis C and blood
- An examination of the nasal cavity to check for disease.
In these tests, hepatitis C RNA was detected using the same sort of technology as a viral load test.
A third of the sample was coinfected with HIV, and 45% with hepatitis B. Hepatitis C viral load varied widely in the sample, with a mean of 5000 copies/ml. Liver function tests for ALT (alanine aminotransferase) indicated some damage, with a mean of 47 u/l.
The researchers were able to detect hepatitis C on 13% of the nasal swabs, and on 5% of the sniffing straws.
Blood was detected in the samples more frequently than hepatitis C. However whether blood was present or not did not predict whether hepatitis could be found. For example, of the five nasal swabs that were positive for hepatitis, there were no traces of blood on two of them.
Pathologies and damage to the nasal passage could increase the risk of hepatitis transmission. Among other problems, more than four out of ten subjects reported having a runny or stuffy nose at least once a week. Rates of inflammation of the nasal membrane were high at 71%, while rates of inflammation of the sinuses were normal.
It is known that hepatitis C can remain infectious outside the body for up to 16 hours. However the authors acknowledge that little is known about the quantity of virus needed for transmission. They suggest that when drugs are being snorted, there is greater discharge of nasal fluids and blood, and the quantity of virus is likely to be larger.
The authors believe that their most significant finding is that hepatitis C can be transferred onto sniffing implements. Nonetheless they recommend further studies to confirm this mode of transmission and its contribution to the spread of hepatitis C.
Reference
Aaron S et al. Intranasal transmission of hepatitis C virus: virological and clinical evidence. Clinical Infectious Diseases 47: 931-934, 2008.
Patients staying on first-line HIV treatment combinations for longer
The introduction of the fixed-dose NRTI combination pills Kivexa ( abacavir and 3TC, called Epzicom in the US) and Truvada ( tenofovir and FTC) in summer 2004 “ushered in a new treatment era for antiretroviral-naïve patients initiating antiretroviral therapy”, write American researchers in the October 1 st edition of AIDS. After the introduction of these combination pills, the investigators found that the amount of time patients remained on first-line treatment increased significantly.
Ease of dosing and improved tolerability were identified by the researchers as the main reasons why patients were able to remain on their treatment for longer.
There is now extremely robust evidence that antiretroviral therapy can significantly improve the prognosis of HIV-positive individuals. Based on knowledge of currently available treatment, once a patient has started HIV therapy it is necessary for him/her to remain on such treatment for life. Although the arsenal of available anti-HIV drugs has increased in recent years, it is important the best possible use is made of the 20 or so drugs available for prescription.
First-line antiretroviral therapy provides the best chance of long-term HIV suppression, and it is important that patients taking such therapy are provided with tolerable and effective drugs.
Researchers at the University of Birmingham in Alabama, one of the largest HIV treatment centres in the southern United States, found that the median duration of first-line antiretroviral therapy between 1996 and 2001 was a little over one and a half years. Early HIV treatment combinations, available in this period, relied on drugs with significant side- effects, that had to be taken in large numbers up to three times a day.
But in more recent years, powerful anti-HIV drugs have become available with fewer side-effects, and requiring only once-daily dosing. A key breakthrough was the licensing in the US in August 2004 of two fixed-dose once-daily nucleoside reverse transcriptase inhibitor (NRTI) pills, Epzicom ( Kivexa in Europe), and Truvada.
Investigators wished to see if the introduction of these pills was associated with an increase in the amount of time patients were able to remain on their first-line antiretroviral treatment.
They therefore designed a retrospective study involving 542 patients who started HIV treatment between January 2000 and July 2007. These patients were divided into two groups: those who initiated therapy before July 31 st 2004, and those who started treatment from August 2004 (when the new fixed-dose pills became available) onwards.
Overall, two-thirds of patients were taking treatment that involved three pills or fewer each day, and 85% of patients were taking a fixed-dose NRTI pill. There was a marked increase in the proportion of patients taking once-daily treatment from just 12% in 2000 to 82% in 2007, and the proportion of patients taking a fixed-dose NRTI also increased over this time period from 77% to 95%.
Use of abacavir or tenofovir as part of an antiretroviral regimen increased from just 6% in the earlier period to 85% for therapy started after August 2004. The increase in the use of these drugs was paralleled by a steep decline in the use of AZT (77% to 14%). The researchers also noted increases in the use of ritonavir-boosted protease inhibitors (from 7% to 23%), NNRTIs (68% to 72%), and the disappearance of triple NRTI therapy (16% to 0%), a strategy shown to involve a high risk of viral rebound and resistance.
Furthermore, the investigators also found that there was a significant decline in the number of patients who stopped treatment within 90 days of initiating therapy with their first antiretroviral regimen (14% to 6%, p < 0.01).
Overall, median duration of treatment with first-line antiretroviral therapy increased from 780 days between 2000 and July 2004 to 1043 days from August 2004 onwards.
Investigators then looked at how long patients were able to stay on their first treatment combination according to its complexity and composition. On average, patients remained on treatment requiring a dose of three or fewer pills a day for 1218 days, compared to just 340 days for pills consisting of six pills or more per dose. Patients taking once-daily treatment stayed on their first combination for 1253 days compared to 712 days for patients taking twice-daily treatment. Combinations including abacavir or tenofovir were much more durable (median 1253 days) than those including d4T or ddI, and patients stayed on NNRTI-based treatment (median 1132 days) for longer than treatment based on a boosted protease inhibitor (median 1043 days).
A series of statistical analyses were then performed by the investigators. They found that, after controlling for patient characteristics, those who initiated therapy before August 2004 were 44% more likely to stop treatment than those who started treatment after the introduction of Epzicom and Truvada (HR = 1.44, 95% CI 1.03 – 2.02).
But when the investigators included dosing frequency in this model, they found that this difference disappeared, but that twice-daily treatment was associated with a 92% increase in the risk of treatment discontinuation compared to once-daily therapy (HR = 1.92, 95% CI 1.29 – 2.88).
Next the researchers looked at the composition of treatment, and this showed that treatment based on anything other than an NNRTI was associated with a greater risk of stopping treatment (for example, boosted protease inhibitor HR = 1.57, 95% CI 1.02 – 4.26). Use of d4T or AZT increased the risk of treatment discontinuation by 116% compared to abacavir or tenofovir (HR = 2.16 95% CI 1.09 – 4.26).
The investigators note that their study has a number of limitations, not least its small sample size and single-centre design. Furthermore, the investigators do not specify the maximum duration of of therapy for patients taking the most modern antiretroviral regimens, nor do the provide details of the reasons driving treatment changes.
“In treatment-naïve patients starting antiretroviral therapy, contemporary intial regimes are more durable than those initiated prior to 2004”, write the inverstigators. Lower pill burden, less frequent dosing, and greater tolerability are offered as likely explanations.
They add, “ the enhanced durability of more modern regimens is encouraging in light of recent data highlighting the importance of uninterrupted antiretroviral therapy”.
Reference
Willig JH et al. Increased regimen durability in the era of once-daily fixed-dose combination antiretroviral therapy. AIDS 22: 1951 – 1960, 2008.
New UK guidelines recommend normalisation of HIV testing in a wide range of healthcare settings
New guidelines for HIV testing, issued on September 18 th, urge healthcare workers of all specialities to consider HIV testing in a wide range of situations and settings. It is part of a package of recommendations to reduce the number of late and undiagnosed HIV infections in the UK. Moreover, in local areas where HIV prevalence is high, testing is recommended for all adults in all healthcare services.
The guidelines have been jointly produced by the British HIV Association (BHIVA), the British Association of Sexual Health and HIV (BASHH) and the British Infection Society (BIS). At the same time, the Medical Foundation for AIDS and Sexual Health (MEDFASH) have released a practical guide for healthcare professionals who do not specialise in HIV, to help them implement the new guidance.
While the 2001 National Strategy for Sexual Health and HIV highlighted a role for GPs in providing HIV testing and other sexual health services, development of that role has been limited. The strategy also recommended that all patients at genitourinary medicine (GUM) clinics be offered an HIV test on their first visit, and the 2006 BASHH guidelines recommended that all GUM patients should be offered HIV tests on an ‘opt-out’ basis. Opt-out means that a test is recommended to the patient and carried out if he or she gives consent.
The 2008 guidelines go much further in envisaging that HIV testing is not only offered as part of a sexual health screen, but during a wide range of other potential encounters with health services. The guidelines aspire to put an end to the ‘AIDS exceptionalism’ which suggested that HIV testing could not be handled by mainstream health services, and that specialised pre- and post- test counselling was required. The guidelines state that: “It should be within the competence of any doctor, midwife, nurse or trained healthcare worker to obtain consent for and conduct an HIV test”.
It is recommended that a pre-test discussion concentrate on the benefits of testing and how the results will be given. Positive results must be given face to face, and the patient should normally be seen by a specialist HIV service within 48 hours of receiving the result. The guidelines recommend that detailed post-test discussions are handled by the specialist HIV team.
The guidelines provide an overlapping set of criteria for when opt-out tests should be proposed, based on healthcare setting, local prevalence, other diagnoses, and the lifestyle and demographic characteristics of the patient.
Testing in specified healthcare settings
Testing is recommended for all patients in the following settings:
- GUM and sexual health clinics
- Antenatal services
- Termination of pregnancy services
- Drug dependency programmes
- Tuberculosis, hepatitis B, hepatitis C and lymphoma services
- Dialysis, blood donation and organ transplant services.
Testing in areas with high HIV prevalence
In local areas where there is already a recognised high prevalence of diagnosed HIV infection, it is assumed that there will also be a high prevalence of undiagnosed infection. In these cases, it is recommended that HIV tests should be offered to all people aged 15 to 59 who register at primary care services or who are admitted to hospital as inpatients.
The Health Protection Agency have analysed existing data on those attending HIV treatment and care services (data come from the Survey of Prevalent HIV Infections Diagnosed, known as SOPHID) to identify those parts of the country where the HIV prevalence is high – in other words, where more than 2 people in 1000 have diagnosed HIV infection.
This is the case for 25 of the 31 Primary Care Trust areas in London, as well as areas such as Brighton & Hove, Manchester, Blackpool, Salford, Bournemouth and Eastbourne that have historically had high HIV prevalence. However there are other areas which have experienced more recent increases in HIV prevalence, including Luton, Watford, Harlow, Southend-on-Sea, Reading, Slough and Crawley.
In total 20% of the English population live in areas where universal opt-out testing is now recommended. However given the novelty of this policy, the guidelines urge that the introduction of universal testing is thoroughly evaluated for acceptability and feasibility.
Testing for patients with specified symptoms or conditions
There are a number of health conditions which may be caused by HIV infection itself, be more common in people with weakened immune systems or, for behavioural reasons, be more common in HIV-positive people than in the general population. At present, many people attending healthcare settings with these conditions are not offered HIV tests and their infection remains undiagnosed.
As well as AIDS-defining conditions such as tuberculosis and cerebral toxoplasmosis, the list of 49 conditions includes:
- Peripheral neuropathy
- Dementia
- Recurrent herpes zoster (shingles)
- Chronic diarrhoea of unknown cause
- Weight loss of unknown cause
- Anal cancer or pre-cancer
- Lung cancer
- Testicular cancer
- Head and neck cancer
- Any sexually transmitted infection
In all of these cases, an offer of an HIV test is recommended.
MEDFASH’s publication provides more information on the links between these conditions and HIV, and also suggests non-stigmatising ways in which clinicians can raise the subject of HIV and gain consent for testing. For example: “We always screen for HIV in patients who have shingles, because very occasionally this can be associated with HIV and we want to make sure we don’t miss anything.”
Clinicians are reminded that the symptoms of primary HIV infection ( seroconversion illness) include fever, rash and muscle pain. However these symptoms can have many different causes. The guidelines recommend that whenever a patient presents with such symptoms and is “perceived to be at risk of infection”, an HIV test should be offered.
Testing for patients with specific lifestyle or demographic characteristics
Testing is recommended for all patients who fall into the following groups:
- Sexual partners of HIV-positive people
- Men who have disclosed that they have sex with other men
- Female sexual partners of men who have sex with men
- People reporting a history of injecting drug use
- People from countries of high HIV prevalence (above 1%)
- Sexual partners of people from countries with high HIV prevalence
Other issues
The guidelines do not recommend repeat testing for most groups of patients, except when a recent infection may not have been identified because of the ‘window period’ (the time after HIV infection when tests are unable to detect infection).
Nonetheless men who have sex with men and injecting drug users should be offered an annual HIV test. However, annual tests are not specifically recommended for people from high prevalence countries.
In terms of testing technology, fourth generation assays (which test both for HIV antibody and p24 antigen) are recommended. These tests have the advantage of reducing the ‘window period’ to one month. The guidelines recommend that results should be available within 72 hours.
The guidelines discuss the use of rapid point-of-care tests which give results in 15 minutes. Because the tests have a high rate of false positive results, their use should not be routine, but is recommended in specific situations, including at community testing sites where HIV prevalence is high and “clinical settings where a rapid turnaround of results is desirable”.
The guidelines also address the testing of infants, children and young people. A separate list of conditions which should prompt HIV testing is provided for use in paediatric settings. The guidelines also highlight cases of vertically infected children whose infection was only identified during their teenage years, and so urges testing of children whose parents are known to have or are suspected to have HIV infection. If a parent does not want the child to be tested, consent issues are complex, but “the overriding consideration must be the best interests of the child”.
References
UK National Guidelines for HIV Testing 2008. BHIVA, BASHH and BIS, September 2008.
Baggaley R HIV for non-HIV Specialists: diagnosing the undiagnosed. MEDFASH, 2008.
For the Health Protection Agency data, click here.
THURSDAY, Sept. 4 (HealthDay News) -- The virus that causes AIDS infects one form of immune T-cell by rearranging its inner skeleton, allowing it access to the cell, scientists have discovered.
The finding helps explain how HIV maintains pockets of dormant virus in these so-called "resting" T-cells, even when the virus is under attack by antiretroviral drugs. It also points to potential new targets for drug development, experts say.
"Whenever you identify a necessary step -- a step which is absolutely required for infection of naive T-cells -- of course then you have a new focus point, one that you can examine to see if there are options for new therapies. Certainly with HIV treatment, we need that," said study co-author Jon Marsh, a researcher in the Laboratory of Cellular and Molecular Regulation at the U.S. National Institute of Mental Health.
Viruses are such primitive life forms that they must gain access to other organisms' genetic material, located deep in the nucleus of the cell, before they can replicate. Scientists have long known that HIV latches onto certain receptors on the surface of its main target -- the immune system's T-cells -- to gain entry into the cell.
Early in the disease process, HIV typically attacks "activated" T-cells -- so named because they are already primed against a particular pathogen. But so-called "nave" T-cells also move throughout the bloodstream. These cells are often resting -- they haven't yet been activated to fight a particular threat.
When HIV seeks entry to the activated T-cell, it does so by latching onto a surface receptor called CCR5. But in more than 50 percent of patients, the virus begins to attack resting T-cells, too, via a receptor called CXCR4.
"We know that HIV prefers to infect activated T-cells -- it's more difficult for HIV to infect resting T-cells," noted Rowena Johnston, vice president of research at the Foundation for AIDS Research (amfAR) in New York City. "So, the question for me and a lot of people has been: Why does the virus do it? What possible advantage could there be?"
In their new research, Marsh and study co-author Yuntao Wu, of George Mason University, believe they may have answered that question. They published the findings in the Sept. 5 issue of Cell.
According to the researchers, HIV binds with the CXCR4 receptor on resting T-cells, and that activates a protein called cofilin. Cofilin effectively rearranges the tiny filaments that make up the T-cells protective inner skeleton. One this is done, HIV is able to sneak past this barrier and into the cell's nucleus.
"So now HIV has a means of making these normally [highly] resistant cells susceptible to infection," Marsh said.
For HIV, there's a decided plus to entering resting versus activated T-cells, because resting cells provide a much safer hiding place, Johnston noted. "If it can get into the resting T-cell, it can just sit in that-cell forever," she explained. "This induces latent infection."
HIV is known to hide out in a number of cell types in the body, making a cure for AIDS elusive. "But if we are aiming to cure infection, we need to understand all of the ways in which latent infection can be established," Johnston said.
HIV's entry into resting T-cells also marks more advanced disease, the experts said. "The emergence of CXCR4 [type virus] usually is late in the disease, and it's usually associated with a relatively severe decline in CD4 T-cells. So, it's not a good sign," Marsh said.
Will this discovery inevitably lead to new, effective AIDS drugs? That remains uncertain, Marsh said.
"The thing about a virus is that it exploits normal processes in a cell," he explained. "So, the clinical aspect always has to look for ways in which you can disturb only the virological component, or most of the virological component, and not hinder those things that are most absolute and necessary for life."
Johnston agreed it may be years, if ever, before this discovery leads to effective therapies. Right now, she said, "this is very much in the arena of just understanding how HIV does what it does."
Justice Edwin Cameron calls for a campaign against 'misguided criminal laws and prosecutions'
“HIV is a virus, not a crime,” argued South African Supreme Court Justice Edwin Cameron during his impassioned call for “a campaign against criminalisation” on the final day of the XVII International AIDS Conference in Mexico City.
Justice Cameron’s plenary presentation was the vocalisation – and culmination – of a growing movement against criminalisation of HIV exposure and transmission that has been supported – and nourished – by organisations as powerful and diverse as UNAIDS and UNDP; the Global Network of People Living with HIV/AIDS (GNP+); the International Community of Women Living with HIV and AIDS (ICW); the International Planned Parenthood Federation (IPPF); the Open Society Institute; the Canadian HIV/AIDS Legal Network; and the AIDS and Rights Alliance for Southern Africa (ARASA); as well as many individual academics and HIV advocates.
Adding to the high-profile voices calling for an end to HIV criminalisation laws was the French HIV/AIDS Ambassador, Louis-Charles Viossat. In a Wednesday afternoon session chaired by Justice Cameron, Ambassador Viossat said that “the fight against criminalisation is the fight against HIV/AIDS itself.”
He stressed that France – currently the president of the European Union – “will fight actively against criminalisation policy. You can count on us,” he added.
He promised that France would circulate evidence regarding criminal laws relating to HIV; set up a taskforce; initiate bilateral discussions with governments about the issue; increase support to HIV treatment and care programmes; and work with minorities and vulnerable populations in partnership with civil society.
However, when reminded that there are several HIV-positive individuals in prison in France who have been convicted of the peculiarly French law of “poisoning”, and asked about whether France intends to decriminalise HIV transmission in its own country, he was unable to make any firm promises.
“As for the national situation,” he said, “this is an internal issue. I am an ambassador, not a lawmaker, but I get your point and I will convey your message.”
Prosecutions: a “distracting and dangerous ‘sideshow’”
Justice Cameron began with an overview of how criminal HIV transmission and exposure laws – both HIV-specific and those that use existing assault legislation – “are stunningly wide in their application and fearsome in their effects.”
Examples included the case of a homeless Texas man sentenced to 35 years in prison because the jury believed he was using his saliva as a deadly weapon; and a young Zimbabwean woman on successful antiretroviral therapy given a five year suspended sentence for HIV exposure.
He also highlighted Egypt’s imprisonment of nine men simply because they were HIV-positive - apparent 'proof' that they were in the "habitual practice of debauchery" – or gay – which is against Egyptian law; and “grievously misguided” HIV exposure laws in Singapore and Switzerland. Such laws are “irrational, unhelpful and resource-sapping,” he said.
In a Tuesday afternoon session examining the impact of criminalisation and alternatives to criminal laws to mitigate the HIV epidemic, Susan Timberlake, UNAIDS’ senior human rights and law adviser, characterised many of the prosecutions seen around the world as “a distracting and dangerous ‘sideshow’”.
She said that although enacting a law criminalising HIV transmission might be seen as a “get tough” measure, it is a “get tough” measure on paper only. Indeed, Justice Cameron said he understood why policymakers and politicians “want to invoke any available and effective means” to deal with the HIV pandemic, including statutes and prosecutions targeting HIV and that “in the abstract and from a distance from social reality, there seems a certain justice that criminal penalty should be applied against those who negligently, recklessly or deliberately pass on the virus, even when there is only a risk of that happening.”
Ten reasons why criminal prosecutions are bad policy
However, he provided ten reasons why creating HIV-specific laws, or applying current assault laws, to anything other than intentional HIV transmission are “misdirected and bad” policy. Many of these arguments were developed from a paper that Justice Cameron recently published in JAMA, co-written with Scott Burris of Temple University Beasley School of Law and Michaela Clayton of ARASA.
- Criminalisation is ineffective since it targets people already diagnosed, when studies show that most HIV transmission takes place during sex between two consenting adults neither of whom is aware that the other is infected with HIV.
- Criminal laws and criminal prosecutions are “shoddy and misguided substitutes” for measures that really protect those at risk of contracting HIV. “We need effective prevention, protection against discrimination, reduced stigma, strong leadership, greater access to testing and most importantly, treatment,” he said.
- Criminalisation victimises, oppresses and endangers women. Although policymakers’ impulse is often to protect women, “it is a grievously misguided impulse” because many laws, especially those in Africa, expose women “to assault, to ostracism and to further stigma” making them “more vulnerable to HIV, not less vulnerable. Rather, he argued, we need laws that guarantee a women’s social and economic status, and that enhance their “capacity to negotiate safer sex and to protect them for predatory sexual partners. We must change the social circumstances that will empower those women to say no when they wish to and to insist on protection when they want to.”
- Criminalisation is often unfairly and selectively enforced. He noted that “prosecutions and laws single out already vulnerable groups like sex workers, men who have sex with men, and in European countries, black males.”
- Criminalisation places blame on one person instead of responsibility on two. “The person who passes on the virus may be more guilty that the person who acquires it,” he said, “but criminalisation unfairly and inappropriately places all the blame on the person with HIV.”
- Criminalisation laws are difficult and degrading to apply. “Those laws that target reckless, or negligent or inadvertent transmission of HIV only introduce uncertainty into an area that is already difficult to police,” he noted. “In court we look back with a clinical harshness of the lawyer's eye on the complexities of these transactions and I do not believe that it is proper for the law to do so.”
- Many HIV-specific laws are extremely poorly drafted. He cited the example of Sierra Leone, based on the African Model Law, which explicitly criminalises mother-to-child transmission and is vague about who will be prosecuted and under what circumstances.
- HIV criminalisation increases stigma. “It is stigma,” he said, “that I believe lies behind the enactment of these bad laws. Those laws seem attractive, but they are not prevention or treatment friendly. They are hostile to both. And this is simply because they add fuel to the fires of stigma. Prosecutions for HIV transmissions and exposure and the chilling content of the laws themselves reinforce the idea of HIV as a shameful, disgraceful, unworthy condition requiring isolation and ostracism.”
- Criminalisation is a blatant disincentive to testing. “Why would a woman in Kenya want to go for an HIV test when she knows that it will expose her to seven years in jail?” he asked.
- Criminalisation assumes the worst about people with HIV, and punishes their vulnerability.
A pragmatic approach
“I want to engage your resolve to practical action today,” Justice Cameron concluded. “Let this be the start of a campaign against criminalisation. Let one of the conference outcomes be a major international pushback against misguided criminal laws and prosecutions.”
However, during a pre-conference meeting of 400 HIV-positive advocates from around the world, Living 2008: the positive leadership summit, it was acknowledged that it might not be possible to revoke all criminalisation laws, and so a more pragmatic approach might be necessary.
This would take the form of using evidence-based advocacy, working together with policy makers, media, criminal justice system, medical specialists, as a form of ‘harm reduction’.
This, noted GNP+’s Christopher Mallouris, would include education for the criminal justice system; education for the media; and education of people living with HIV regarding their legal rights and responsibilities where they reside, or travel.
Finally, if instead of a punitive model, a human rights approach to HIV and the law is followed, focused on strengthening laws that:
- support people to protect themselves from infection;
- empower infected individuals to avoid infecting others;
- allow people to be able to know their status and disclose it, or practise safer behaviours without coercion or fear;
- and allow women to be able to determine the conditions under which they have sex or children, or not, then, argued UNAIDS’ Susan Timberlake, in the July 2008 issue of IPPF’s HIV/AIDS Update “empowerment will remove any need for the application of criminal law to HIV transmission, because there will be no cases deserving of criminal sanction; only tragic ones that could and should have been avoided, had the right support been in place.”
References
Burris S and Cameron E. The case against criminalization of HIV transmission JAMA 300(5): 578-581, 2008 (Also published in longer form, and available for free as: Burris S, Cameron E, Clayton M. The criminalisation of HIV: time for an unambiguous rejection of the use of criminal law to regulate the sexual behavior of those with and risk of HIV.
Cameron E. Criminal statutes and criminal prosecutions in the epidemic: help or hindrance? 17th International AIDS Conference, Mexico City, abstract FRPL0103, 2008. (Audio, video and transcript available at kaisernetwork.org.)
Mallouris C. Punishments that do not match the 'crime': Understanding the impact of criminalizing HIV transmission. 17th International AIDS Conference, Mexico City, abstract TUSAT2601, 2008. (Powerpoint presentation available.)
Timberlake S. Answers and alternatives: a more nuanced approach towards the criminalization of HIV. 17th International AIDS Conference, Mexico City, abstract TUSAT2606, 2008. (Powerpoint presentation available.)
Timberlake S. Any alternatives? HIV/AIDS Update 14, IPPF, July 2008. (Available to download from the IPPF website).
Viossat L-C. In session: Criminalization: why, where and what are the alternatives? 17th International AIDS Conference, Mexico City, abstract WESY0905, 2008.
Process of HIV-related dementia is found
United Press International - August 20, 2008
NEW YORK , Aug. 20 (UPI) -- U.S. scientists say they have found evidence that a component of the cell walls of intestinal bacteria help the human immunodeficiency virus enter the brain.
The Albert Einstein College of Medicine researchers said in up to 20 percent of people infected with HIV, the virus manages to escape from the bloodstream and cross into the brain, resulting in HIV-associated dementia and other cognitive disorders.
The Yeshiva University scientists said their findings might lead to the development of strategies for preventing HIV from entering the brain.
"Previous research has suggested that it's not individual HIV viruses that get into the brain, but rather HIV-infected immune cells known as monocytes," said Dr. Harris Goldstein, senior author of the study. "Using an animal model, we wanted to find out first of all whether being infected with HIV enables monocytes to do what they don't usually do -- escape from blood vessels and enter brain tissue."
They discovered that being infected with HIV somehow gives monocytes the capacity to cross an intact blood brain barrier, said Goldstein. The study is detailed in the Journal of Virology.
Disclaimer: Please don’t assume that GMFA or the London Gay Men’s HIV Prevention Partnership endorse or oppose the points of view of the authors. Please read these articles critically. Sometimes articles may contain mis-statements, we believe they are important to include because of the information they contain or the arguments they put forward. If you have a story or article on STI or HIV prevention which you would like to be distributed please forward it to lgmhpp.update@gmfa.org.uk.
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