Willingness to Act Upon Beliefs about ‘Treatment as Prevention’ among Australian Gay and Bisexual Men

HIV ‘treatment as prevention’ (TasP) is highly effective in reducing HIV transmission in serodiscordant couples. There has been little examination of gay and bisexual men’s attitudes towards TasP, particularly regarding men’s willingness to act on beliefs about TasP. 

We conducted an online cross-sectional survey of Australian men in late 2012 to investigate knowledge and beliefs about new developments in HIV prevention. 

• Amongst 839 men (mean age 39.5 years), men tended to disagree that TasP was sufficiently effective to justify reduced condom use, although HIV-positive men had more favourable attitudes. 
• Only a minority of men were aware of any evidence for TasP; and 
• one-quarter incorrectly believed that evidence for the effectiveness of TasP already existed for the homosexual population. 
• One-fifth (20.5%) of men reported that they would be willing to have condomless anal intercourse with an opposite-status sexual partner when the HIV-positive partner was taking HIV treatments. 
• Factors independently associated with such willingness were: 
• HIV-positive serostatus, 
• reporting any serodiscordant or serononconcordant condomless anal intercourse with a regular male partner in the previous six months, 
• reporting any condomless anal intercourse with a casual male partner in the previous six months, and 
• having greater beliefs in the effectiveness of TasP. 
• This indicated that the men most willing to rely on TasP to prevent transmission were already engaging in higher risk practices. 
• Biomedical HIV prevention represents a rapidly changing environment with new research as well as community and policy responses emerging at a fast pace. 

For men with serodiscordant sexual partners to successfully apply TasP to reducing transmission risk, more support and education is needed to enable better utilisation of TasP in specific relational and sexual contexts.

Below:  Individual scale items for total sample, and comparison between HIV-positive and non-HIV-positive men (bivariate)

Full article at:   http://goo.gl/wcB0dH

By:  

Benjamin R. Bavinton, Andrew E. Grulich, Iryna B. Zablotska, Garrett P. Prestage

Kirby Institute, University of NSW Australia, Sydney, Australia

Martin Holt

Centre for Social Research in Health, University of NSW Australia, Sydney, Australia

Graham Brown, Garrett P. Prestage

Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia

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Hepatitis C Virus Treatment as Prevention in People Who Inject Drugs: Testing the Evidence

PURPOSE OF REVIEW:

The majority of hepatitis C virus (HCV) infections in the United Kingdom and many developing countries were acquired through injecting. New clinical guidance suggests that HCV treatment should be offered to people with a transmission risk - such as people who inject drugs (PWID) - irrespective of severity of liver disease. We consider the strength of the evidence base and potential problems in evaluating HCV treatment as prevention among PWID.

RECENT FINDINGS:

There is good theoretical evidence from dynamic models that HCV treatment for PWID could reduce HCV chronic prevalence and incidence among PWID. Economic evaluations from high-income settings have suggested HCV treatment for PWID is cost-effective, and that in many settings HCV treatment of PWID could be more cost-effective than treating those at an equivalent stage with no ongoing transmission risk. Epidemiological studies of older interferon treatments have suggested that PWID can achieve similar treatment outcomes to other patient groups treated for chronic HCV. Impact and cost-effectiveness of HCV treatment is driven by the potential 'prevention benefit' of treating PWID. Model projections suggest that more future infections, end stage liver disease, and HCV-related deaths will be averted than lost through reinfection of PWID treated successfully for HCV. However, there is to date no empirical evidence from trials or observational studies that test the model projections and 'prevention benefit' hypothesis. In part this is because of uncertainty in the evidence base but also there is unlikely to have been a change in HCV prevalence due to HCV treatment because PWID HCV treatment rates historically in most sites have been low, and any scale-up and switch to the new direct acting antiviral has not yet occurred. There are a number of key uncertainties in the data available on PWID that need to be improved and addressed to evaluate treatment as prevention. These include estimates of the prevalence of PWID, measurements of HCV chronic prevalence and incidence among PWID, and how to interpret reinfection rates as potential outcome measures.

SUMMARY:

Eliminating HCV through scaling up treatment is a theoretical possibility. But empirical data are required to demonstrate that HCV treatment can reduce HCV transmission, which will require an improved evidence base and analytic framework for measuring PWID and HCV prevalence.

Full article at:   http://goo.gl/xyuGQF

By:   Hickman M¹, De Angelis D, Vickerman P, Hutchinson S, Martin NK.

¹aSchool of Social and Community Medicine, University of Bristol bMRC Biostatistics Unit, University of Cambridge and Public Health England cGlasgow Caledonian University and Health Protection Scotland, UK dDivision of Global Public Health, University of California San Diego, California, 

Curr Opin Infect Dis. 2015 Dec;28(6):576-82. doi: 10.1097/QCO.0000000000000216. 

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Increased Prevalence of Controlled Viremia and Decreased Rates of HIV Drug Resistance among HIV-Positive People Who Use Illicit Drugs During a Community-Wide Treatment-as-Prevention Initiative

BACKGROUND:

Although treatment-as prevention (TasP) is a new cornerstone of global human immunodeficiency virus (HIV)-AIDS strategies, its effect among HIV-positive people who use illicit drugs (PWUD) has yet to be evaluated. We sought to describe longitudinal trends in exposure to antiretroviral therapy (ART), plasma HIV-1 RNA viral load (VL) and HIV drug resistance during a community-wide TasP intervention.

METHODS:

We used data from the AIDS Care Cohort to Evaluate Exposure to Survival Services study, a prospective cohort of HIV-positivePWUD linked to HIV clinical monitoring records. We estimated longitudinal changes in the proportion of individuals with VL <50 copies/mL and rates of HIV drug resistance using generalized estimating equations (GEE) and extended Cox models.

RESULTS:

Between 1 January 2006 and 30 June 2014, 819 individuals were recruited and contributed 1 or more VL observation. During that time, the proportion of individuals with nondetectable VL increased from 28% to 63% (P < .001). In a multivariable GEE model, later year of observation was independently and positively associated with greater likelihood of nondetectable VL (adjusted odds ratio = 1.20 per year; P < .001). Although the proportion of individuals on ART increased, the incidence of HIV drug resistance declined (adjusted hazard ratio = 0.78 per year; P = .011).

CONCLUSIONS:

We observed significant improvements in several measures of exposure to ART and virologic status, including declines in HIV drug resistance, in this large long-running community-recruited cohort of HIV-seropositive illicit drug users during a community-wide ART expansion intervention. Our findings support continued efforts to scale up ART coverage among HIV-positive PWUD.

Purchase full article at: http://goo.gl/58J4iB

By:   Milloy MJ1, Wood E1, Kerr T1, Hogg B2, Guillemi S3, Harrigan PR1, Montaner J1.

• 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver.
• 2British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
• 3British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital. 

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Investigating Combination HIV Prevention: Isolated Interventions or Complex System

INTRODUCTION:

Treatment as prevention has mobilized new opportunities in preventing HIV transmission and has led to bold new UNAIDS targets in testing, treatment coverage and transmission reduction. These will require not only an increase in investment but also a deeper understanding of the dynamics of combining behavioural, biomedical and structural HIV prevention interventions. High-income countries are making substantial investments in combination HIV prevention, but is this investment leading to a deeper understanding of how to combine interventions? The combining of interventions involves complexity, with many strategies interacting with non-linear and multiplying rather than additive effects.

DISCUSSION:

Drawing on a recent scoping study of the published research evidence in HIV prevention in high-income countries, this paper argues that there is a gap between the evidence currently available and the evidence needed to guide the achieving of these bold targets. The emphasis of HIV prevention intervention research continues to look at one intervention at a time in isolation from its interactions with other interventions, the community and the socio-political context of their implementation. To understand and evaluate the role of a combination of interventions, we need to understand not only what works, but in what circumstances, what role the parts need to play in their relationship with each other, when the combination needs to adapt and identify emergent effects of any resulting synergies. There is little development of evidence-based indicators on how interventions in combination should achieve that strategic advantage and synergy. This commentary discusses the implications of this ongoing situation for future research and the required investment in partnership. We suggest that systems science approaches, which are being increasingly applied in other areas of public health, could provide an expanded vocabulary and analytic tools for understanding these complex interactions, relationships and emergent effects.

CONCLUSIONS:

Relying on the current linear but disconnected approaches to intervention research and evidence we will miss the potential to achieve and understand system-level synergies. Given the challenges in sustaining public health and HIV prevention investment, meeting the bold UNAIDS targets that have been set is likely to be dependent on achieving systems level synergies.

Full article at:   http://goo.gl/EBwg30

By:   Brown G1,2, Reeders D1, Dowsett GW1,3, Ellard J1,4, Carman M1, Hendry N1, Wallace J1.

• 1Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia.
• 2Centre for Social Research in Health, University of New South Wales, Sydney, Australia; Graham.brown@latrobe.edu.au.
• 3Centre for Social Research in Health, University of New South Wales, Sydney, Australia.
• 4Kirby Institute, University of New South Wales, Sydney, Australia. 

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HIV Sexual Transmission Risks in the Context of Clinical Care: A Prospective Study of Behavioural Correlates of HIV Suppression in a Community Sample, Atlanta, Georgia

Below;  (a) Percent of participants receiving ART, ART adherent and achieving HIV suppression and (b) sexual HIV transmission risks among individuals with suppressed and unsuppressed HIV.

Individuals with unsuppressed HIV demonstrated a constellation of behavioural risks for transmitting HIV to uninfected sex partners that included symptoms of STI and substance use. In addition, 15% of participants with suppressed HIV had recent STI symptoms/diagnoses, indicating significant risks for sexual infectiousness despite their HIV suppression in blood plasma. Overall, 38% of participants were at risk for elevated sexual infectiousness and just as many engaged in unprotected sexual intercourse with non-HIV-infected partners.

Implementation strategies for using HIV treatments as HIV prevention requires enhanced behavioural interventions that extend beyond ART to address substance use and sexual health that will otherwise undermine the potential preventive impact of early ART.

Read more at:   http://ht.ly/QNhsq HT @UConn