THEGAYUK

Tag: The Lancet

  • With effective treatment HIV risk is zero in gay men

    European study of nearly 1,000 gay male couples who had sex without using condoms – where one partner was HIV positive and on suppressive antiretroviral therapy (ART) and the other HIV negative – reports no cases of within-couple HIV transmission over 8 years.

    PrEP pills
    (C) marcbruxel Depositphotos

    A European study of 972 gay male serodifferent couples, in which one partner was on suppressive antiretroviral therapy (ART), has found no cases of HIV transmission within couples over 8 years of follow up.

    The observational study, which is the largest of its kind and published in The Lancet, provides conclusive evidence that having an undetectable viral load (less than 200 copies/mL) on ART means that the virus is untransmittible.

    Over 8 years of follow up in the study, 15 HIV-negative men became infected with HIV, but none of the viruses screened in the newly infected partner were genetically linked to the HIV virus that had infected their main partners, ruling out any within-couple HIV transmissions.

    Importantly, the researchers estimate that effective ART prevented around 472 HIV transmissions during the 8 years of the study.

    Regular testing is still important

    The authors emphasise the importance of regular monitoring and supporting people with long-term adherence to therapy and caution that the effectiveness of ART in preventing HIV transmission is dependent on ensuring that the virus remains undetectable in the blood.

    The results support the international U=U (undetectable equals untransmittable) campaign, that has been endorsed by more than 780 HIV organisations in 96 countries, to raise awareness of how scientific evidence shows that effective ART means people living with HIV can have sex without fear of transmitting the HIV virus to others.

    “Our findings provide conclusive evidence for gay men that the risk of HIV transmission with suppressive ART is zero,” says Professor Alison Rodger from UCL, UK, who co-led the research. “Our findings support the message of the international U=U campaign, that an undetectable viral load makes HIV untransmittable. This powerful message can help end the HIV pandemic by preventing HIV transmission, and tackling the stigma and discrimination that many people with HIV face. Increased efforts must now focus on wider dissemination of this powerful message and ensuring that all HIV-positive people have access to testing, effective treatment, adherence support and linkage to care to help maintain an undetectable viral load.” [1]

    The new study, PARTNER2, assessed the risk of HIV transmission between serodifferent (one partner is HIV-positive, one is HIV-negative) gay male couples not using condoms. The results add to an earlier phase of the PARTNER study, which found that HIV transmission risk for serodifferent heterosexual couples was zero.

    The first phase of the PARTNER study, which took place between September 2010 and May 2014 and was published in 2016, recruited and followed up 1,116 serodifferent couples who were not using condoms. Of these, 888 couples, both heterosexual (548 couples) and gay men (340 couples), provided 1,238 eligible years of follow up from 14 European countries. The second phase of the study (PARTNER2) included gay male couples only.

    Between September, 2010 and July, 2017, 972 gay couples were recruited, of which 782 provided 1,593 eligible years of follow up—the main reasons couples weren’t included in the analysis were because no condomless sex was reported, they had used pre-exposure or post-exposure prophylaxis (PrEP or PEP), or HIV viral load or HIV test results were not available.

    Couples had frequent follow-up (every 6-12 months) to complete confidential questionnaires on their sexual behaviour, to test HIV-negative partners for HIV, and to measure plasma HIV-1 viral load in the HIV-positive partner. If HIV-negative partners became infected with HIV, genetic testing was done to see whether the virus was genetically similar to their study partner’s virus, or was acquired from another sexual partner.

    At the start of the study, the couples had already been having sex without condoms for a median of 1 year, and the HIV-positive partners had been on ART for a median of 4 years, with high adherence (98% participants reported 90% adherence).

    During an average of 2 years follow-up (per couple), couples had anal sex without condoms a total of 76,088 times (equivalent to about once a week).

     

    Bru-nO / Pixabay

    During the study, over a third (37%; 288/777) of HIV-negative men reported having sex without a condom with other partners. Around a quarter of HIV-positive (214/779) and HIV-negative (185/779) men reported at least one STI such as syphilis and gonorrhoea (table 2) since their last visit. Only 5% (37/779) of HIV-positive men reported missing ART for more than 4 consecutive days.

    The authors note several limitations, including that most HIV-negative gay men were white with an average age of 38 years—yet most HIV transmission occurs in young people aged 25 years or younger. Additionally, the majority of HIV-positive partners had been on suppressive ART for several years, so the authors had limited data on transmission risk during the initial months of ART.

    Commenting on the implications of the findings in a linked Comment, Dr Myron Cohen from the UNC Institute for Global Health and Infectious Diseases, USA writes: “These important results serve to inspire and challenge us. Timely identification of HIV-infected people and provision of effective treatment leads to near normal health and lifespan and virtual elimination of the risk of HIV transmission. Yet maximising the benefits of ART has proven daunting, especially for men who have sex with men It is not always easy for people to get tested for HIV or find access to care; in addition, fear, stigma, homophobia, and other adverse social forces continue to compromise HIV treatment. Furthermore, diagnosis of HIV infection is difficult in the early stages of infection when transmission is very efficient, and this limitation also compromises the treatment as prevention strategy…The results of the PARTNER2 study provide yet one more catalyst for a universal test-and-treat strategy to provide the full benefits of antiretroviral drugs. This and other strategies continue to push us toward the end of AIDS.”

  • HIV death rates halved since 1999

    HIV-positive adults in high-income countries face a substantially reduced risk of death from AIDS-related causes, cardiovascular disease, and liver disease compared with a decade ago, according to a large international study published in The Lancet.

    The study which involved nearly 50 000 HIV-positive adults receiving care and antiretroviral therapy (ART) at more than 200 clinics across Europe, USA, and Australia found that overall death rates have almost halved since 1999.

    The development in the mid-1990s of antiretroviral treatment for the management of HIV infections is one of medicine’s greatest success stories. For individuals who can access and adhere to treatment at early stages of the infection, the risk of developing an AIDS-defining complication is vanishingly small. Treatment, however, does not fully restore health. Treated adults have a higher than expected risk of developing many non-AIDS complications including cardiovascular disease and cancer. The excess risk has been attributed to antiretroviral drug toxicity, traditional risk factors, immune dysfunction, or chronic inflammation. With the advent of effective antiretroviral treatment, the life expectancy for people with HIV is now approaching that seen in the general population. Consequently, the relative importance of other traditionally non-AIDS-related morbidities has increased. The team behind the study investigated trends over time in all-cause mortality and for specific causes of death in people with HIV from 1999 to 2011.

    The team behind the study noted that their findings suggest that death rates in HIV-positive individuals with access to care and antiretroviral therapy have decreased since 1999-2000. They can detect no indication of an increase in risk of death from any specific cause as a potential result of long-term adverse effects of ART, and the risk of death from other causes – ie, those other than AIDs-related disease, cardiovascular disease, liver disease, and non-AIDS cancers – is low.

    Rates of death from non-AIDS-related cancers have remained stable over time, and these types of cancers are now the most common cause of non-AIDS deaths in people with HIV. The finding of a stable rate of death from non-AIDS cancer in the study is of concern when compared with the experience in the general population, in which death rates have decreased over the same time period.

    However a potential limitation to the study is that the investigators could only report on the outcomes of HIV-infected individuals who were followed up regularly in clinic, and thus excluded a large population of HIV-infected individuals who remain untreated because they are unaware of their infected status or not engaged in care.

    Steven Deeks and Peter Hunt from the University of California in San Francisco, USA, say, ‘The benefits of ART are unquestioned, and their beneficial effect on the HIV epidemic continues to grow. Still, clear limitations exist because many patients are not accessing treatment, and some problems persist even in those on ART, including a higher than expected risk of non-AIDS cancers and other morbidities. Finally, it needs to be emphasised that we are still early in the ART era. In the absence of a cure, most patients will need to continue on ART for decades. Continued monitoring for unexpected consequences of treatment will be needed indefinitely.’

    To read the article, see below:
    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60604-8/abstract

  • The Lancet: Causes of death shifting in people with HIV

    HIV-positive adults in high income countries face a substantially reduced risk of death from AIDS-related causes, cardiovascular disease, and liver disease compared with a decade ago, according to a large international study published in The Lancet.

    The study which involved nearly 50 000 HIV-positive adults receiving care and antiretroviral therapy (ART) at more than 200 clinics across Europe, USA, and Australia found that overall death rates have almost halved since 1999, while deaths due to AIDS-related causes and cardiovascular disease have declined by around 65% and liver-related deaths by more than 50%.
    Although deaths from most causes declined over the study period, there was no reduction in death rates from non-AIDS cancers which remained stable over time (1.6 deaths per 1000 years 1999–2000 to 2.1 in 2009–2011). Non-AIDS cancers are now the leading cause of non-AIDS deaths in people with HIV, accounting for 23% of all deaths.

    Using data from the Data collection on Adverse events of anti-HIV Drugs (D:A:D) study, the researchers looked at trends in underlying causes of death in people with HIV between 1999 and 2011, who were followed-up for a median of 6 years.
    Of the 3909 deaths that occurred over the study period, around 29% of individuals died from an AIDS-related cause, which remains the most common cause of death. Cancers (15%; mainly lung cancer) were the most frequent causes of non-AIDS deaths, followed by liver disease (13%; mainly due to hepatitis), and cardiovascular disease (11%).

    Mortality decreased from about 17.5 deaths per 1000 person-years in 1999–2000 to 9.1 deaths per 1000 years in 2009–2011—a drop of around 50%. Similar decreases in deaths related to AIDS (5.9 deaths per 1000 person-years to 2.0), liver disease (2.7 to 0.9), and cardiovascular disease (1.8 to 0.9) were also seen. The proportion of all deaths due to AIDS (34% to 23%) and liver disease (16% to 10%) declined over the decade, while the proportion of deaths due to cardiovascular disease remained constant at 10%.

    The researchers note that substantially reduced death rates from liver and cardiovascular disease cannot be fully explained by changes in patient demographics or improvements in viral suppression or CD4 count, and might result from the better management of traditional risk factors such as smoking, alcohol use, and hepatitis, or the use of less toxic ART regimens.

    They conclude by calling for further research to gain a clearer understanding of why the risk of dying from a non-AIDS cancer remains high and to assess the effect of specific antiretroviral drugs on non-AIDS cancer rates.

    According to study leader Dr Colette Smith from University College London in the UK, ‘These recent reductions in rates of AIDS-related deaths are linked with continued improvement in CD4 count and provide further evidence of the substantial net benefits of ART. But despite these positive results, AIDS-related disease remains the leading cause of death in this population. Continued efforts to ensure good ART adherence and to diagnose more individuals at an earlier stage before the development of severe immunodeficiency are important to ensure that the low death rate from AIDS is sustained and potentially decreased even further.’*

    Writing in a linked Comment, Steven Deeks and Peter Hunt from the University of California in San Francisco, USA, say, ‘The benefits of ART are unquestioned, and their beneficial effect on the HIV epidemic continues to grow. Still, clear limitations exist because many patients are not accessing treatment, and some problems persist even in those on ART, including a higher than expected risk of non-AIDS cancers and other morbidities. Finally, it needs to be emphasised that we are still early in the ART era. In the absence of a cure, most patients will need to continue on ART for decades. Continued monitoring for unexpected consequences of treatment will be needed indefinitely.’

    The study appears in a special issue of The Lancet published ahead of AIDS 2014, the 20th international AIDS conference of the IAS, taking place in Melbourne, Australia, from 20-25 July, 2014.