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England’s PrEP policy in disarray after NHS U-turn
individuals at risk of HIV, and clinicians have reacted with anger to an
official U-turn on provision of HIV pre-exposure prophylaxis (PrEP). NHS
England officials have refused to allow a draft policy on PrEP to go forward
for further consideration.
“The UK once had a reputation for being a leader in HIV
prevention and that reputation now lays in tatters,” said Will Nutland of
activist group Prepster. “NHS England
has turned its back on a process that could have significantly contributed to
turning the tide of HIV in this country. The decision is ill-conceived, is not
based on evidence, and will directly contribute to the on-going sexual ill
health of the nation.”
argument advanced by NHS England for the U-turn is that they shouldn’t
have been considering commissioning PrEP in the first place, as HIV prevention
services are the responsibility of local authorities. While many think these
arguments to be disingenuous, PrEP appears to be a victim of the split of
commissioning responsibilities between the NHS and local authorities.
“We are perplexed and deeply concerned by NHS England's
decision,” said the British
HIV Association (BHIVA), representing clinicians. “This is yet another
adverse outcome of the disastrous Health and Social Care Act.” Local
authority leaders have rejected the idea that they could foot the bill for
the medications used in PrEP without additional funding.
Although NHS England argue that they should not be providing
PrEP, they simultaneously offer a sliver of funding for a pilot project.
Activists and clinicians rejected this as inadequate to meet the needs of
people vulnerable to HIV.
People who are concerned about PrEP and the state of HIV
prevention in the UK are
urged to write to their MP and ask them to raise the issue with the
Secretary of State for Health and also to sign a parliamentary petition.
survey of 532 HIV-positive gay men attending clinics in England and Wales has
found very high rates of ‘chemsex’ and of drug injecting. The survey results were presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2016) held in Boston in February. The figures are
of particular concern because they are not based on users of specialised
services for people using drugs, but of people attending HIV clinics who were
ready to complete a survey covering many aspects of their health and wellbeing.
These data are likely to be more representative than some previously published
Of the HIV-positive gay men completing the survey, 29%
reported chemsex (‘the use of drugs to increase disinhibition and sexual
arousal’) in the past year. Furthermore, 10% reported injecting – or being
injected with – drugs in a sexual context.
Figures were higher for some subgroups: Londoners,
middle-aged (rather than younger) men, men reporting depression.
Users were six times less likely to report always using
condoms than other men. They reported 30 sexual partners a year, whereas other
men had an average of just under 10. The odds of reporting a sexually
transmitted infection or hepatitis infection were much higher than in other
The results of two studies conducted in four African
countries announced at CROI 2016 show that vaginal rings impregnated with an anti-HIV drug were
effective at cutting the HIV infection rate in women.
However, the overall effectiveness seen was only moderate,
preventing less than a third of infections that would otherwise have happened.
The primary reason for this was that the rings had no effect at all in the
youngest trial participants, aged 18 to 21 – who also had the highest rates of
HIV infection. The rings were more effective in older women, preventing almost
two-thirds of infections in women over 25 in one of the two studies.
These poorer-than-expected results could be caused by a
combination of factors – intrinsic efficacy of the rings of less than 100%,
intermittent use among participants (who tended to take them out for cleaning,
especially while menstruating or during sex), and greater vulnerability to HIV
infection among young women. But whether these are the reasons for the
relatively low levels of adherence and lack of effect seen in young women
remains to be seen.
An open-label study – in which participants will know that
they are receiving a partially-effective ring and not a placebo – will now take
place. The rationale of this is that in some studies, adherence and
effectiveness have been higher in people who know they are receiving an active product.
If results are promising, then there would be an application for a product
licence from early 2017.
The Conference on Retroviruses and Opportunistic Infections
(CROI 2016) included several studies looking into possible future ways to
deliver PrEP, as alternatives to pills containing tenofovir and emtricitabine (Truvada). The most important of these studies
are those into vaginal rings, described above. In addition:
the new version of tenofovir – which has less impact on the kidneys and
bones – is distributed differently in the body, which could mean that it won’t
be suitable for PrEP. Concentrations in rectal and genital tissues in women
were lower than expected.
CCR5 inhibitor maraviroc (Celsentri) could have a role in PrEP when
used alongside either of the component drugs in Truvada but is
not potent enough to act as PrEP in itself. Maraviroc is of interest because it
has few side-effects and few problems with resistance.
is probably no population that is both more heavily impacted [by HIV] and less
discussed around the world than transgender people,” Susan Buchbinder of
the San Francisco Department of Public Health told CROI 2016.
A meta-analysis of 39 studies from 15 countries
found that transgender women had an HIV prevalence rate of 19% – 49 times
higher than that of the general population. Three studies that estimated annual
incidence, or new infections, reported rates of 1.2 to 3.6% a year.
But there are hardly any data on transgender men. The HIV statistics published by Public Health
England do not include specific figures for transgender people, although this
may be about to change.
Factors that increase trans people’s vulnerability to HIV
include stigma, fear of disclosure, sexual networks that include more people
with HIV, poverty, lack of employment opportunities which leads many trans
women to engage in sex work, unstable housing, violence, problems accessing
health care, drug use, and mental health issues such as depression.
Also, hormone therapy could potentially cause changes in
rectal or vaginal mucosa that increase susceptibility to HIV. There is also the
possibility that hormones might interact with PrEP – and trans women’s concern
about this may be one factor behind sometimes low adherence to PrEP.
In England, hardly any prevention programmes have begun to
understand and engage with the needs of trans men or trans women.
Scaling up testing and treatment
Interventions aimed at improving the proportion of people
diagnosed with HIV, linked to care and remaining on treatment were a major
theme at this year's conference. Several large
programmes in African countries are testing the feasibility of offering testing
and treatment at a very large scale, essential for achievement of the 90-90-90
target of 90% diagnosed, 90% of diagnosed people on treatment and 90% of those
on treatment virally suppressed.
findings from the large PopART study in Zambia and South Africa showed that
after one round of household-based testing, linkage to care and offer of
immediate antiretroviral treatment, 90% of adults knew their HIV status and 71%
of adults diagnosed with HIV were on treatment. Progress was a little slower
than hoped, with people generally taking a few months to begin HIV treatment.
When the study is complete it will tell us whether this test-and-treat approach
has an impact on new HIV infections in the study communities.
is already close to reaching the 90-90-90 target and is ahead of the United
States and most European countries in its efforts to improve treatment
coverage, the conference heard. Based on a random sample of households in the
country, it appears that 83% of people living with HIV know their status, 87%
of those diagnosed are taking treatment and 96% of those on treatment have an
undetectable viral load.
Other recent news headlines
Several large sexual health clinics in London and
Brighton have responded to the growing numbers of people importing PrEP
medications from overseas by offering free safety monitoring to PrEP users. This is in a context of increasing frustration with delays to the official NHS process to approve PrEP.
An analysis of
condom use in the placebo-controlled phase of the French IPERGAY trial of
intermittent pre-exposure prophylaxis (PrEP), presented at CROI 2016, found that just over
half of the participants had high levels of PrEP use but rarely used condoms, and
about a quarter were “belt-and-braces” users who had high levels of both PrEP
and condom use.
A study comparing the sexual behaviour of American gay men
living in states with or without laws that criminalise HIV transmission has
found very little variation by state, suggesting that legislation has minimal
impact on public health. Or the law may be counter-productive – men who believed
they lived in a state which criminalised HIV transmission were slightly more
likely to have sex without a condom, the researchers report in AIDS & Behavior.
Editors' picks from other sources
from The Body
if I have sex without a condom, something bad eventually has to
happen." I can understand how this fear operates. The first year I used
PrEP and had condomless sex with both HIV-positive, and
HIV-negative-identified partners, I still carried that fear. My
40-year-old mind simply could not absorb that feeling good wouldn't
result in a painful outcome.
from The Independent
HIV prevention and support services are facing closure after being
earmarked for cuts by local authorities across the country, leaving
potentially thousands of people with the virus cut adrift. So far, six
councils – Oxfordshire, Bexley, Portsmouth, Slough, Bromley and
Bracknell Forest – have proposed a decommissioning of HIV support
services, effective from 1 April.
from Drug and Alcohol Findings
Blood-borne infections such as hepatitis C can be spread by the sharing
of contaminated injecting equipment. Individuals infected with hepatitis
C can be cured through antiviral treatments, a prospect made more
realistic by the new range of more easily tolerated and more rapidly
acting medications. Not only does cure forestall the development of
severe liver disease, it also means that (barring re-infection) the
injector will no longer be able to spread the virus to others.
London Mayoral candidate Sadiq Khan has warned against complacency on
HIV – after statistics showed that a disproportionate amount of
Londoners are living with HIV.
providers need to understand that for HIV-positive African women,
following advice not to breastfeed in order to protect their babies from
the virus takes a high emotional toll, a UK study suggests.