Apologies for the delay in getting the last couple of updates to you, but the closing couple of days went into overdrive, as there were various social events on Thursday night which meant I wasn’t able to get my notes written up. Then on Friday I only had time for a bite to eat before getting on a plane home, which got me back to London this afternoon.
So here’s how Thursday went:
The day started very well, with an excellent session providing an overview of Treatment As Prevention (TAsP) from a variety of perspectives. We started with a report back from the TAsP Workshop held in April this year and delivered by the clinician who has been at the forefront of promoting TAsP on a global level – Julio Montaner of Canada. Refreshingly, he started by reminding us that treatment is primarily to prevent morbidity and mortality, rather than HIV transmission. Clearly, ant-retroviral therapy (ART) is the most effective way to reduce the risk of illness and death for people with HIV, but in recent years it has sometimes felt like this has been less newsworthy than its ability to prevent HIV transmission. He went on to highlight that in relation to prevention it was a far more effective tool than PrEP (in all populations) and should be more attractive from a prescribing perspective, given the benefits firstly to the patient and then to their partners. This was a crucial component of UNAIDS’ new 90-90-90 targets ( having 90% of people diagnosed, on treatment and with an undetectable viral load by 2020). For more detailed info you can check out the www.treatmentaspreventionworkshop.org website.
Clinical effectiveness was next on the agenda, as Dr Karim from S Africa spoke of the CAPRISA trial and the fact that starting ART earlier (now recommended at a CD4 count of 500 and at any count for serodicordant couples, pregnant women and children under 5) has resulted in a 11-year increase in life expectancy in the country. It’s worth mentioning that for a country that has 0.7% of the world’s population, S Africa has 17% of HIV infections. They still have huge problems, with transmission still very high ( especially in young girls) and a majority still not knowing they have HIV (despite 13 million tests in 2010/11), but they have been scaling up access to ART, with 52% of those diagnosed getting it.
Edwin Bernard from the UK (ex-editor of NAM’s HIV Treatment Update and now the person behind the HIV Justice Network campaign to challenge HIV criminalisation) presented a human rights perspective. While there are potentially many rights-related benefits of TAsP (life, liberty, security, health, non-discrimination, freedom of movement, ability to found a family and more), many of these are also potentially risked when you look at the in the context of countries with laws criminalising behaviours such as same sex relationships, sex work and drug use. While there is also clearly a potential to challenge stigma as far as transmission risk is concerned, we are also then at risk of creating a ‘virological sub-class’ of those who have detectable virus. Mandatory testing is also a risk, as we have seen in Greece, where police have arrested, forcibly tested and imprisoned sex workers who have HIV. He also noted that TAsP will not succeed fully until everyone has access to affordable non-toxic drugs, which is currently not the case, with many countries still using old ARVs which would not be prescribed in this country.
Nukshinaro Ao told of first-hand personal experiences of trying to access treatment in rural Thailand, where getting transport to the clinic (rather than walking, which would take a day to get there and back) would cost a week’s wages! This is a common problem for many rural areas and has be addressed if we are going to achieve effective scale-up of access to ART and all the benefits it brings. When stigma and discrimination of the very people Edwin was speaking of is also factored in, the likelihood of getting treatment is further reduced. In order to make effective use of TAsP, three things are needed – access to care for all, support and information to ensure people stay in care and on ART and address stigma and discrimination so that people can access and stay supported in care.
Finally, Fabio Mesquita, who is Brazil’s health ministry lead on HIV and hepatitis, spoke of some of their successes in the areas of treatment availability, access and supportive legislation to ensure that no-one is excluded (including a recent law criminalising HIV discrimination). Despite much work, only 25% of people living with HIV have an undetectable viral load, and so he was presenting the projects (many of which were providing peer support initiatives to engage and retain people in care) and new guidelines (treatment for all at any CD4 count) that Brazil was financing, with the aim of getting a 30% increase in number of people on treatment within the next year.
The afternoon sessions had a focus on gay and other men who have sex with men, looking at prevention issues in what is an accelerating epidemic in both the global north and south, in high-, middle- and low-income countries. The irony was noted that it was gay men who spear-headed campaigns and awareness of HIV, yet are now the only group of people on a global level among whom the epidemic is continuing to rise, being the population most at risk of contracting HIV. Rather than go through the wide variety of presentations which covered this issue across all the continents, I will highlight the specific issues and areas that were covered, since there were many overlaps.
In San Francisco, gay men account for 62% of all new infections, with a majority of transmissions taking place within a relationship. Looking at the agreements that gay men made when in relationships (as far as monogamy or the level of openness in a relationship was concerned) highlighted the need for clear and open communication, as those who had clear understandings had less risk.
In Thailand, Peru, Nigeria issues around having sex at saunas, outside of the home, not feeling able to talk about HIV status and using alcohol and drugs were respectively all associated with higher risk of contracting HIV. Support and programmes were being factored into these settings in response to the research findings. In Australia, while many gay men used risk reduction strategies including condoms, disclosure/serosorting, strategic positioning (eg. being only the top when not using condoms), withdrawing before ejaculation, risk reduction strategies were least likely to be used by HIV- men when having sex with men they believed to be HIV- or with untested regular parters. This is clearly a major issue, which also came up in the final presentation.
This interesting study compared levels of HIV in gay men in London and San Francisco, since there are clear similarities between the cities, but for some reason the rates of new infections and diagnoses are both now going down in SF, whereas in London they are stable or increasing. This is despite much better access to care and levels of people who have undetectable viral load in London. Some of the crucial issues seem to be that SF are down to 7% undiagnosed whereas London has only got down to 20% and there are more new infections being diagnosed in London (3 times as many as in SF). There are higher reported levels of unprotected sex amongst men who are (or think they are) HIV negative in London. We already know that in the UK, the majority of new infections come from people who don’t know they have HIV, but this comparison really struck home when you looked at the higher rates of STIs (and Hep C reinfection amongst HIV+gay men). There are also much higher levels of HIV disclosure in San Francisco, where there has been a long history of speaking about it publicly as a community (with 1 in 4 gay men living with HIV, versus 1 in 10 in London). Finally, although both cities have large populations of gay men who move to the city to live a gay life, London seems to have higher levels of people being diagnosed here (with 1 in 5 new diagnoses in 2011 being among people who were not born in the UK). The key points to address were to achieve higher levels of HIV testing and disclosure and to provide more information campaigns about risk and testing (THT’s recent ‘It Starts With Me’ campaigns were highlighted as a good example of where we should be going, in the conversation about untested versus positive and undetectable on treatment). Lisa Power raised a relevant point in the Q&A about the fact that SF has unified funding and prevention plan, driven by a city council that clearly prioritises HIV as a health issue, whereas London-wide council funding has been dismantled and needs to be reintroduced to achieve the necessary gains. For more info, check out Gus Cairns piece for aidsmap.
That’s all for Thursday’s sessions, as I mentioned earlier, I had tickets to the theatre for some downtime in the evening, and then it was on to the ‘No Pant No Problem‘ fundraiser party, which was as fun as it sounds (though do remember that it’s the American use of the term, so no trousers for those attending, rather than being underwear free!).
I’ll post the final day’s update tomorrow, hopefully after a good night’s sleep in my own bed tonight!
All the best