Nine ways funding for the global HIV response could go further

A young girl living with AIDS takes her drugs at her home in Ndiwa, western Kenya. Photograph: Simon Maina/AFP/Getty Images

Story via The Guardian

1 | Protect and promote human rights

Public resources are wasted on enforcing laws that criminalise HIV transmission and dehumanise at-risk populations. By contrast, laws that protect at-risk populations are powerful, low-cost tools that help ensure that financial and scientific investments for HIV are not wasted. Enacting laws based on sound public health and human rights will ensure new prevention and treatment tools – such as PrEP [pre-exposure prophylaxis], male circumcision and microbicides – reach those who need them. Changes in the legal and policy environment, along with other interventions, could lower new adult HIV infections to an estimated 1.2 million by 2031 (compared to 2.1 million if current efforts continue unchanged). Mandeep Dhaliwal, UNDP

2 | Make drugs cheaper

One way to make limited funds go further is to challenge drug companies on the high price of life-saving drugs. The use of unmerited patents by pharmaceutical companies to secure monopolies on their products must stop. Make Medicines Affordable is working with civil society to challenge unmerited patents and useTrips agreement flexibilities. Julia Powell, International Treatment Preparedness Coalition

In lower middle-income countries, the average antiretroviral (ARV) treatment cost for a new adult patient is around $350 [£283]. Of that, just 40% is the cost of the ARV – 35% is non-ARV recurrent costs (clinical salaries, laboratory etc) and then 25% is programme management. We really need to dissect non-drug costs and find ways to reduce costs with regard to generic licensing and optimising manufacturing costs. Anand Reddi, Gilead Sciences

3 | Support LGBT groups

There are some great new global funds supporting funding for local and national LGBT groups so that they can gather data on access to medicines for their community, in a way that ensures their confidentiality and safety. The Rapid Response Fund, funded by the Elton John Aids Foundation (EJAF), the President’s Emergency Plan for Aids Relief (Pepfar) and UNAids, will support civil society organisations that are led by, or work closely with, MSM [men who have sex with men] and LGBT people and communities, to implement rapid responses to situations or events that threaten their access to HIV services. Grants of up to $20,000 [£16,000] are available. Mike Podmore, STOPAIDS

4 | Support adherence to ARVs

Drug resistance is a huge issue and one to which we are only just waking up. The World Health Organisation has produced a 2017-21 action plan which, I think, underlines that we have neglected to focus on adherence and support people not just to access ARVs, but to stay on them. Mike Podmore

5 | Integrate HIV into health sectors

Finance ministers tend to think in terms of sectors (eg health) or a clusters of sectors (eg the social sectors – education, health, social welfare), rather than in terms of individual issues like HIV. We need to integrate Aids financing into domestic health financing and make the argument to finance ministers that they need to increase investment in the social sectors, and health in particular. We need to underscore why this is an important investment in human capital and, therefore, in economic development. David Wilson, World Bank

6 | Collect and spend taxes on health

Some countries with major HIV epidemics have actually progressively reduced the share of the government budget they allocate to health, and many African countries with major HIV challenges collect a smaller share of GDP as revenue – and spend more collecting that small share – than comparable economies elsewhere. We must ensure that a significant share of the greater revenue collected is allocated to health, and spent as efficiently as possible. David Wilson

7 | Integrate HIV and water and sanitation programmes

Safe water can make an enormous difference to the health and wellbeing of people living with HIV. It can increase drug effectiveness by reducing diarrhoea and collaboration between HIV specialists at Safaids and in the water and sanitation sector have identified ways to integrate water and HIV programming more effectively in southern Africa to streamline investments. In addition, arecent systematic review showed that water and sanitation interventions to reduce morbidity among people living with HIV were cost-effective, particularly when incorporated into complementary programmes. Louisa Gosling, WaterAid

8 | Coordinate responses

In the HIV/Aids space, we can work with others focusing on health to share costs. In Malawi, for example, our mobile clinic teams test and treat for malaria and TB even though our core focus is HIV. Also, in our door-to-door testing pilot – where a team of eight canvases a village over a week to perform HIV tests – that same team will check for bed nets. If they do not have one, our HIV testing team will leave one and teach the family how to use it. One team, but two major health issues covered. Joel Goldman, The Elizabeth Taylor AIDS Foundation

9 | Push for more funding

We must reject the assumption that we will/can have less money and, instead, make it clear that less money, or even maintaining the same levels of funding, will lead to an increase in infections and deaths globally. Many organisations working on the global HIV and TB responses are shouting loudly about the funding alarm. It became even more urgent when the Kaiser Family Foundation found that global donor financing had reduced by 13% from 2014 to 2015. Our only way forward is to increase general public awareness and demand for donors and INGOs to increase HIV and TB funding up to 2020, and make it possible to end the epidemics by 2030. If not, we risk a terrifying rebound of the epidemics that we will struggle to get a grip on again. Mike Podmore

Read the full Q&A here.

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The world needs a healthier, rights-based approach towards people who use drugs

The world is failing to protect the health and human rights of people who use drugs.

As a result, people who use drugs, especially people who inject drugs, have been isolated and denied the means to protect themselves from HIV, hepatitis C, tuberculosis and other infectious diseases.

Among the estimated 12 million people who inject drugs globally, one in 10 is living with HIV. From 2010 to 2014, there was no decline in the annual number of new HIV infections among people who inject drugs, in contrast to the global trend of declining new HIV infections.

The evidence is overwhelming. The world needs a fresh approach towards people who use drugs that is people-, rights- and health-centered.

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In a new report, Do no harm: health, human rights and people who use drugs, UNAIDS presents the evidence for what works to reduce the impact of HIV and other harms associated with drug use. Countries that have shifted their focus away from laws and policies that are harmful to people who use drugs and that have increased investment in harm reduction programs have reduced new HIV infections and improved health outcomes.

For example, investment in needle-syringe distribution and opioid substitution therapy has proved effective at reducing the impact of the AIDS epidemic among people who inject drugs in several countries, including China, the Islamic Republic of Iran and the Republic of Moldova.

China’s free voluntary methadone program piloted in the early 2000s now serves more than 180 000 people. People who inject drugs represented less than 8% of people newly diagnosed with HIV in the country in 2013, compared with 43.9% in 2003. In prisons in the Islamic Republic of Iran, health clinics provide integrated services for the treatment and prevention of sexually transmitted infections and for injecting drug use and HIV, and new HIV cases among people who inject drugs fell from a peak of 1897 in 2005 to 684 in 2013. In the Republic of Moldova, the proportion of prisoners living with HIV having access to antiretroviral medicines has increased from 2% in 2005 to 62% in 2013.

Some countries, such as Australia, the Netherlands, Portugal and Switzerland, have de-penalized the possession and use of small quantities of drugs for personal use, encouraging people who inject drugs to access strengthened harm reduction programs.

UNAIDS would like to see a global adoption of a people-centered, public health and human rights based approach to drug use.

The world cannot continue to ignore what works.

In the coming weeks, the United Nations General Assembly will have two opportunities to consider the weight of evidence supporting a change in approach. This week’s United Nations General Assembly Special Session on the World Drug Problem provides an opportunity to refocus international drug policies on their original goal—the health and well-being of humankind. A few weeks later, from 8 to 10 June, the General Assembly will meet again for the High-Level Meeting on Ending AIDS, which must translate commitments to leave no one behind in the AIDS response into measurable progress for people who inject drugs.

There is a unique opportunity to begin to treat people who use drugs with dignity and respect, to provide people who use drugs with equal access to health and social services, to greatly reduce the harms of drug use and to take a step towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals.

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The tragedy that ‘chemsex’ drugs can cause

Image by Tom Robson for the LASS Shooting Challenge “Unsafe Sex“

At the beginning of last year, Henry Hendron would have been forgiven for thinking he had it all – a successful career as a barrister, representing high-profile figures and politicians, a flat in the heart of London, and a happy, loving relationship.

But just a few weeks later, it lay in ruins. His 18-year-old boyfriend, Miguel Jimenez, was dead from an overdose. Hendron was arrested and later charged with supplying drugs – his career and his freedom both in jeopardy.

Story via BBC

In an interview with BBC Radio 4’s Today programme, Hendron has told how his partner’s death weighs heavily on his shoulders.

Last week, at the Old Bailey, Hendron pleaded guilty to two charges of possession with intent to supply Class B and Class C drugs. He will be sentenced in early May, with the judge telling him that “all sentencing options remained open”. BBC producer Alexander Parkin had earlier admitted two counts of supplying controlled drugs.

Whether or not Hendron is jailed, it almost certainly means the end of a successful career as a barrister.

He says he is not pleading for sympathy or expecting special treatment from the courts. He holds himself entirely responsible for his situation – and the death of his boyfriend.

“Every day that goes past I feel responsible. I was older, I should have known better, I was 34 then, he was only 18. It should have been me saying ‘we’re not going to do this’ … I didn’t make that call when I should have done, and for that reason, and that reason alone, I put his tragic death on my shoulders.”

He believes party drugs are wrecking the lives of many young gay men.

“It was a normal Monday afternoon. We had taken our dog to the vet. We had dinner, we had some wine, and my partner had quite a bit of wine, and then at midnight he just said ‘shall we have some drugs?’

“I was working the next day, so I didn’t have any on that occasion, but he did. He had some G [GHB]. It was quite a nice experience and we went to sleep. I woke up and he was dead, next to me.

“I’d never seen a dead person before but when I turned him over, he was non-responsive, he was purple in the face and his face was frozen.”

Hendron says he then attempted CPR to revive Miguel while waiting for the ambulance to arrive at his flat in Temple, in central London.

The paramedics, who arrived alongside officers from the City of London Police, worked for three-quarters of an hour but were unable to save Miguel.

“I think I let out a wail. I was just in another mental, different place. All of a sudden, my whole world had collapsed from being happy and healthy and being in a loving relationship, to one which had this big question mark.

“My partner was dead in the next room, and as the ambulance retreated, four or five police officers came forward and arrested me … for various drugs charges and manslaughter at that time.”

It was that moment, handcuffed in his flat in the heart of London’s legal district, and being taken away for questioning, that reality dawned.

“I was there because of drugs, my partner was dead because of drugs and I was about to lose my career because of drugs.”

Drugs, he says, are “common and increasing phenomenon” on the gay scene. The media reports of the case asserted that Miguel had taken the drugs at a party, but Hendron denies this.

He had bought a large quantity of both mephedrone and GHB (commonly known as G) not for a so-called “chemsex” party but to share with his partner, he says. But the chemsex scene – gay men using drugs like mephedrone and GHB to enhance sex – is one that he had become caught up in over recent years.

“There wasn’t a party on the night Miguel died. It was just him and me. But I am familiar with that scene, unfortunately so. I hadn’t touched drugs in my teens and twenties, it was only the last couple of years.

“There are a large number of men, in their 30s and 40s, who’ve come to drugs late and are now doing it regularly. Drugs in the gay scene have really taken off. Recent studies show that gay people are three times more likely to take drugs than their straight counterparts.

“It seems to be the acceptable face now of recreation in the gay community.”

In fact, the British Medical Journal published an editorial last year suggesting that chemsex needed to become a public health priority.

The pioneering sexual health clinic, 56 Dean Street in London, estimates that 3,000 gay men who use drugs in a sexual setting access its services every month.

Who are these people? In Hendron’s experience, people very much like him. Professionals, holding down jobs during the week.

“Most of the people who do these gay sex high parties are in full-time employment. It’s not a picture that most people aren’t part of that scene would recognise.

“The problem is more prevalent than people think and it’s an increasing one. It’s increasing because the drugs are cheap, and they’re everywhere. Within minutes on [gay dating app] Grindr, in Vauxhall or Soho, you can find someone who’s selling or looking.”

Hendron says he regularly goes to Miguel’s native Colombia where he was buried, and has got to know his family, especially his mother. “It’s a horrific thing to lose a son, especially at 18 and to drugs. And to make matters worse, not all of his family knew he was gay so you have many bombshells that dropped on their shoulders at the same time.”

Hendron accepts he has done wrong.

“I may go to prison and whatever I get, I deserve. I have made some stupid decisions and you have to stand up and accept that.

“But that’s the price that drugs make you pay.”
 

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Bill Gates predicts HIV vaccine by 2030

Bill and Melinda Gates speak at Davos. Photograph: Ruben Sprich/Reuters

Bill Gates believes that a vaccine and new intensive drugs to combat HIV should be available by 2030 and end most new cases of the virus that has killed millions in the past three decades.

The Microsoft founder, whose philanthropic foundation spends tens of millions of dollars on medical research, told the World Economic Forum in Davos that the two “miracles” were within reach.

“We’re pretty optimistic in this 15-year period we will get those two new tools,” he said.

A vaccine was seen as being pivotal in preventing infections among susceptible populations, while new kinds of intense drug treatments should do away with the need for life-long treatment, he added.

The billionaire founded the Bill & Melinda Gates Foundation in 2000. The couple said in their annual letter about the foundation’s work that, along with progress toward a vaccine or a cure, the number of people getting treatment for HIV in sub-Saharan Africa would finally outstrip the number of new infections.

“When we reach that point in the region with the most dense HIV transmission in the world, cases will start going down everywhere around the globe for the first time since the disease was discovered more than 30 years ago,” they wrote.

Gates was also optimistic about the battle against malaria, where work on a vaccine is more advanced than for HIV.

GlaxoSmithKline filed the world’s first malaria vaccine for approval in July 2014.

“We won’t see the end of Aids,” Gates told the Davos forum last Friday. “But both for malaria and Aids we’re seeing the tools that will let us do 95-100% reduction. Those tools will be invented during this 15-year period.”

Bill and Melinda Gates also predicted in their annual letter that the lives of people in developing countries would improve faster in the next 15 years than at any other time in history.

In the UK there are an estimated 100,000 people living with HIV infection – both diagnosed and undiagnosed – of whom about 40% are gay men.

A drug called Truvada has been found in trials – when used as a pre-exposure prophylaxis (PrEP) in HIV negative people at risk of getting the virus – to reduce the transmission of HIV, but has not yet been approved or funded by the NHS for this. The drug may also be used in people who have been exposed to HIV, in combination with another drug, such as raltegravir. This is known as post-exposure prophylaxis (PEP).

There have been growing calls to make Truvada more widely available as a preventative measure in Britain, particularly to gay men.

via Guardian

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The Reason Why Experimental HIV Vaccines Backfire

“This study shows that if a vaccine induces high levels of activated CD4+ T cells in mucosal tissues, any potential protective effect of the vaccine may be hampered,” senior author Guido Silvestri explains.

HIV Vaccines Should Avoid Viral Target Cells, Primate Model Study Suggests

Vaccines designed to protect against HIV can backfire and lead to increased rates of infection. This unfortunate effect has been seen in more than one vaccine clinical trial.Scientists at Yerkes National Primate Research Center, Emory University, have newly published results that support a straightforward explanation for the backfire effect: vaccination may increase the number of immune cells that serve as viral targets. In a nonhuman primate model of HIV transmission, higher levels of viral target cells in gateway mucosal tissues were associated with an increased risk of infection.The findings, published in Proceedings of the National Academy of Sciences , suggest that vaccine researchers, when evaluating potential HIV/AIDS vaccines, may need to steer away from those that activate too many viral target cells in mucosal tissues.

“One of the reasons why it has been so difficult to make an AIDS vaccine is that the virus infects the very cells of the immune system that any vaccine is supposed to induce,” says senior author Guido Silvestri, chief of microbiology and immunology at Yerkes National Primate Research Center.

Silvestri is also a professor of pathology and laboratory medicine at Emory University School of Medicine and a Georgia Research Alliance Eminent Scholar. The first author of the paper is senior research specialist Diane Carnathan, PhD, and colleagues from the Wistar Institute, Inovio Pharmaceuticals and the University of Pennsylvania contributed to the study.

A large part of the HIV/AIDS vaccine effort has been focused on developing vaccines that stimulate antiviral T cells. T cells come in two main categories, defined by the molecules found on their surfaces. CD8 is a marker for “killer” cells, while CD4 is a marker for “helper” cells. CD4+ T cells are known to be primary targets for HIV and SIV (simian immunodeficiency virus) infection, while several studies have proposed that CD8+ T cells could be valuable in controlling infection.

In this study, researchers immunized rhesus macaques with five different combinations of vaccines encoding SIV proteins found on the inside of the virus only. This experimental strategy was designed to examine the effects of cell-mediated immunity, without stimulating the production of neutralizing antibodies, in what scientists refer to as a “reductionist approach”.

The monkeys received an initial immunization followed by two booster shots after 16 and 32 weeks. The monkeys were then exposed to repeated low-dose intrarectal challenge with SIV, once per week, up to 15 times. In general, the immunization regimens did not prevent SIV infection. While all the immunized monkeys had detectable levels of circulating “killer” CD8+ T cells, there was no correlation between these cells and preventing infection.

The most important result, however, was that the monkeys that became infected had higher levels of activated CD4+T cells in rectal biopsies before challenge, Silvestri says.

“This study shows that if a vaccine induces high levels of activated CD4+ T cells in mucosal tissues, any potential protective effect of the vaccine may be hampered,” he explains.

The study emphasizes the unique challenges that HIV poses in terms of vaccine development, and the importance of pursuing vaccine concepts and products that elicit strong antiviral immune responses without increasing the number of CD4+ T cells in the portals of entry for the virus.

The research was supported by the National Institute of Allergy and Infectious diseases (AI080082) and the NIH Director’s Office of Research Infrastructure Programs (Primate centers: P51OD11132).

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Contraceptive injection raises risk of HIV, research warns

The implications of a possible link between hormonal injections and HIV alarm campaigners. Photograph: Alamy

Lancet analysis finds 40% increase in infection risk for women using birth control jab compared with other hormonal methods

Contraceptive injections moderately increase a woman’s risk of becoming infected with HIV, a large scientific analysis has found.

The research in a leading medical journal will further fuel a controversy that has been raging for more than two decades. The implications of a possible link between hormonal injections and the virus alarm both HIV and birth control campaigners. Some countries in sub-Saharan Africa, where HIV rates are high, have considered withdrawing the contraceptive injections entirely from family planning clinics. About 41 million women use the jabs, in many cases because it allows them to control their fertility without their husband’s knowledge.

The analysis, in the journal Lancet Infectious Diseases, finds that in the pooled results of 12 observational trials, there is a 40% increase in the risk of HIV for women using the birth control jab compared with other hormonal methods such as the pill.

The US authors, from the University of California at Berkeley, said this was a moderate increase in risk. What it means for each individual woman will depend on her risk of HIV infection to begin with. For most women, the risk of an unwanted pregnancy and possibly death – maternal mortality rates are high in sub-Saharan Africa – may outweigh the increased risk of HIV.

For groups of women such as sex workers who have a high risk of HIV infection, the implications may be more alarming. However, the authors said there were only two studies that focus on this specific group and so the results were not conclusive.

The lead author of the research said the evidence was not strong enough to justify the complete withdrawal of depot medroxyprogesterone acetate (DMPA), more commonly called Depo-Provera, from women in the general population.

“Banning DMPA would leave many women without immediate access to alternative, effective contraceptive options. This is likely to lead to more unintended pregnancies, and because childbirth remains life-threatening in many developing countries, could increase overall deaths among women,” said epidemiologist Lauren Ralph.

But, she added: “Further evidence regarding the magnitude and mechanisms of the DMPA and HIV link among high-risk women, such as commercial sex workers and women in serodiscordant partnerships (where one partner is HIV-positive and the other is not), is urgently needed.”

The possible rise in HIV infections among women using the contraceptive jab was first noted in 1991. The debate over it has become “increasingly narrow and fierce”, said Christopher Colvin from the University of Cape Town in South Africa and Abigail Harrison from Brown University School of Public Health in the US in a comment in the journal.

“Like many scientific controversies, views have become hardened, personal, financial, or political agendas have been suggested, and there has even been intrigue in the form of leaked copies of articles under peer review,” said the commentary.

“Both sides have raised important, compelling arguments, but their partisan character can weaken the quality of the debates and restrict the view of the complex relation between evidence, policy, and practice.”

The debate is currently focused on whether there should be a large randomised controlled trial. This would need to compare HIV infections of women using the birth control jab probably with another group using the pill. Some would say that in the light of current evidence that would be unethical. Others warn a trial may not be decisive.

Colvin said that although trials can sometimes be the best option, they have their limitations.

“I do think that the debate over the trial, in both public and scientific circles, tends towards framing a trial as the way to ‘get the answer’ … which makes me nervous,” he told the Guardian.

The World Health Organisation advises that women at high risk of HIV should be told that the injectables “may or may not increase their risk of HIV acquisition”. Couples should be informed and given access to other methods, including male and female condoms.

Story via The Guardian

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The NHS urgently needs to make PrEP available

Two European studies of pre-exposure prophylaxis (PrEP), PROUD¹ and IPERGAY², reported early results in October 2014. Both studies showed that PrEP was so effective at preventing HIV transmission that everyone in these studies has now been offered PrEP. The comparison arms, which respectively offered delayed PrEP or a placebo, have been closed.

In light of this news, together with data on continued high rates of new infections³, the NHS urgently needs to make PrEP available.

Although an NHS England process to evaluate PrEP is underway, any decision to provide PrEP will probably not be implemented until early 2017, which is too long to wait. We are calling for earlier access to PrEP. The NHS must speed up its evaluation process and make PrEP available as soon as possible. Furthermore, we call for interim arrangements to be agreed now for provision of PrEP to those at the highest risk of acquiring HIV.

What is PrEP?

PrEP stands for Pre-Exposure Prophylaxis. It involves a person who doesn’t have HIV taking pills regularly to reduce their risk of HIV infection. Several studies show that PrEP works.

PrEP is currently only available in the UK to people enrolled in the PROUD study,⁴ but has been available in the US since 2012.

Why do we need PrEP?

There are now over 100,000 people living with HIV in the UK. ⁵ We need to improve HIV prevention.

Tens of thousands of HIV transmissions have been prevented by condom use.⁶  However many people do not use condoms all of the time and each year there are thousands of new infections. PrEP has the potential to prevent new infections among some of those at greatest risk of acquiring HIV.

Condom use will remain a core strategy in HIV prevention. PrEP gives people who already find it difficult to consistently use condoms an additional way to protect their health.

Due to the high rate of HIV infections, there is a particular need for the NHS to make PrEP available to gay men. However it should be available to all people who are at high risk of acquiring HIV.

How effective is PrEP?

Research suggests that PrEP is as effective as condoms in preventing HIV transmission, as long as the pills are taken regularly, as directed. Evidence from a large international study suggests that gay men who maintained at least four doses a week had 96% fewer infections.^{7 8} Preliminary results from separate studies of PrEP in the UK⁹ and France¹⁰ both show that PrEP substantially reduces infections among gay men. Full results are expected early in 2015. PrEP has also proven effective for heterosexual couples in which one partner is HIV positive and not on HIV treatment.¹¹

PrEP does not prevent other sexually transmitted infections or pregnancy. It allows someone to protect their own health, irrespective of whether their partner uses a condom. Because it is taken several hours before sex, it does not rely on decision-making at the time of sex.

Why take HIV treatment to avoid taking HIV treatment?

People living with HIV need to take lifelong treatment. PrEP consists of fewer drugs and people only need to take it during periods when they are at risk of HIV. Many people find that their sexual behaviour changes over time, for example when they begin or end a relationship.

Does PrEP have side-effects?

Any medicine can have side-effects, so taking PrEP is a serious decision. The drugs in PrEP have been used as part of HIV treatment for many years. This has shown that they have a low risk of serious side-effects. Most people taking PrEP don’t report side-effects. Some people have stomach problems, headaches and tiredness during the first month but these usually go away. People taking PrEP have regular check-ups at a clinic.

Does PrEP mean people take more risks?

The full results of the PROUD study will help us understand the impact of PrEP on condom use among gay men in the UK. But other studies of PrEP have consistently reported that being on PrEP did not result in people adopting riskier behaviours. ^{12 13  14} Instead it gives people who already find it difficult to consistently use condoms a way to protect their health.

                                                        

References

1. http://www.proud.mrc.ac.uk/PDF/PROUD%20Statement%20161014.pdf
2. http://www.aidsmap.com/Second–European–PrEP–study–closes–placebo–arm–early–due–to–higheffectiveness/page/2917367/
3. Public Health England. HIV in the United Kingdom: 2014 Report. London: Public Health England. November 2014.
4. For more information, http://www.proud.mrc.ac.uk
5. Public Health England. HIV in the United Kingdom: 2014 London: Public Health England. November 2014.
6. Phillips AN et al. Increased HIV Incidence in Men Who Have Sex with Men Despite High Levels of ART–Induced Viral Suppression: Analysis of an Extensively Documented Epidemic. PLoS ONE 8(2): e55312. doi:10.1371/journal.pone.0055312.
7. Grant RM et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. New England Journal of Medicine 363:2587-2599, 2010.
8. Anderson PL et al. Emtricitabine–tenofovir concentrations and pre–exposure prophylaxis efficacy in men who have sex with men. Science Translational Medicine 4: 151ra125, 2012.
9. http://www.proud.mrc.ac.uk/PDF/PROUD%20Statement%20161014.pdf
10. http://www.aidsmap.com/Second–European–PrEP–study–closes–placebo–arm–early–due–to–higheffectiveness/page/2917367/
11. Baeten JM et al. Antiretroviral Prophylaxis for HIV Prevention in Heterosexual Men and Women. New England Journal of Medicine 367: 399-410, 2012.
12. Marcus JL et al. No Evidence of Sexual Risk Compensation in the iPrEx Trial of Daily Oral HIV Preexposure PLoS ONE 8: e81997, 2013.
13. Mugwanya KK et al. Sexual behaviour of heterosexual men and women receiving antiretroviral pre–exposure prophylaxis for HIV prevention: a longitudinal analysis. Lancet Infectious Diseases 13: 1021–28, 2013. ¹⁴ Grant RM et al. Uptake of pre–exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infectious Diseases 14: 820-829, 2014.

Via NAM

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Young, British, and Living With HIV

“I remember not getting out of bed other than to use the loo. My friend had to stay with me just to make sure I was eating,” says ​Niyi Maximus Crown, a 25-year-old man who was diagnosed HIV positive in December 2011. “I didn’t even recognize my own thinking voice. I felt like I was going to be single for the rest of my life. The feelings of worthlessness made me angry and I started to hate myself.”

Last week, ​Public Health England (PHE) released its ​latest report on HIV. “In the UK there are 107,800 people living with HIV,” says Eleanor Briggs, Assistant Director of Policy and Campaigns at National AIDS Trust. In London, almost one in eight gay and bisexual men are HIV positive. Based on the stats from PHE, Briggs adds, “We can say about a third of people living with HIV infection, both diagnosed and undiagnosed, were resident in London.”

What’s more frightening is that PHE estimates that 24 percent of the people in the UK with HIV are currently undiagnosed.

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Early diagnosis of HIV is crucial. Briggs states that a late diagnosis can mean treatment becomes less effective, reducing a person’s lifespan. Medication also helps stop the spread of HIV by lowering the amount of HIV virus in a positive person to undetectable levels so they are ​unlikely to pass it on.

And yet few people are talking honestly about HIV. In terms of everyday knowledge on the gay scene, HIV exists somewhere in limbo between the grim ​tombstone adverts of the 80s, statistics that get bounced around annually from numerous health organizations and the raw realities of chemsex-fuelled bareback sessions. The subject usually makes an appearance in the media once a year when ​World AIDS Day rolls around. A leading HIV consultant ​told the BBC that there’s a “complete lack of awareness” of the risks among many gay men in the UK.

As gay venues up and down the country prepare to mark World Aids Day (on December 1) with fundraising events for various LGBT charities, though, how many people do you know are comfortable with talking openly about being HIV positive? Do you even know anyone that’s openly HIV positive?

The truth is that, as a community, we still drive people who live with HIV into the closet. It’s not surprising that most gay men feel they want to keep their status private. Many struggled during their lives to come out as gay to their friends, families or work colleagues, and they may not even be out in all aspects of their lives. Having to then deal with the stigma that still exists around being HIV positive is akin to having to deal with a second coming out and, once again, another round of judgement and shame.

A few HIV negative people share their thoughts. “If you get HIV from unprotected sex you deserve it,” said one. Many might privately agree with him. But does that mean they deserve to feel forever alienated by society?

Niyi is better known in London’s gay clubs as Maximus Crown. He is one of the only DJs that is publicly out about being HIV positive, which is a big deal. The UK gay scene has very few openly HIV positive DJs, drag queens or promoters. But Niyi didn’t really have the choice of whether he should put his status out there—his best friend at the time decided to go public with it on Facebook for him.

“My best friend stayed with me every day to make sure that I wasn’t alone, didn’t starve or try and kill myself,” Niyi recalls. “Six months later I decided to distance myself from him because I started to notice things about our friendship that I wasn’t OK with. To get back at me he went onto the Facebook event page for a party I was booked to DJ at and posted a series of comments about me being HIV positive.”

The comments included accusations that Niyi had been having unprotected sex while aware he was HIV positive. “When it happened I wasn’t angry, I just wanted to log out of the universe. If I could have closed my eyes and stopped existing I would have, but it forced me to own my status, which in turn made me more comfortable discussing it publicly.”

If you are old enough to remember ​the campaigns of the 80s, then safer sex and the issues around HIV would have been drummed into your consciousness. But with the advent of combination therapy and the dramatic development of antiretroviral drugs that revolutionized care over the last fifteen years, AIDS-related deaths dropped substantially. Between 2001 and 2011, the rate of new infections ​dropped by 20 percent.

As the number of deaths fell, though, so too did government resources that educated people about HIV. Schools barely touched on the subject. To most people, it was seen as a disease that only affected poorer countries. It’s no wonder that the number of infections in young people has risen comparatively steeply compared to other age groups. As the ​United Nations Population Fund say, young people remain at the centre of the HIV epidemic in terms of rates of infection, vulnerability, impact, and potential for change. The young have grown up in a world changed by AIDS, but so many still lack the correct knowledge about how to prevent HIV infection. ​

For many recently infected guys, getting their head around living with HIV is one of the biggest challenges.

James Hanson-McCormick, 24, who was 18 when he was diagnosed with HIV said “I had no idea what HIV was or how it was contracted. I have had six years to think about my status, and not a single day goes by without me thinking about it. It’s so hard. I wish I knew more [then], I wish I had been better educated and that I knew enough to try and prevent it happening.”

It might sound naïve, but James isn’t alone in his experience. ​Luke Alexander is from Oldbury, a small town outside Birmingham, and was diagnosed HIV positive in June 2013. He was 18. “If I was in a sexual relationship with a guy when I was 15 or 16 it was monogamous,” he tells me. “When I hit 18 I treated myself to a fancy phone and discovered these apps and clubs. You’re new to everything and people say ‘download this’ and you find people want to hook up with you. It’s validation. You become quite promiscuous.”

Luke’s candidness took me aback. “I became incredibly egotistical and quite narcissistic,” he admits. “Add drugs and alcohol into the equation and it becomes quite a habit. One thing led to another and I didn’t take any precautions.”

Will Harris, Head of Media for ​Terrence Higgins Trust, says that while research shows that most gay men use condoms most of the time, it only takes one instance of unprotected sex for HIV to be passed on. “Condom use has to be consistent… It’s basic human nature to under-estimate risk, so our community needs to keep finding ways to reinforce the message that ‘He looks fine, it’ll probably be OK’ won’t give you the protection that a condom will.”

Earlier this year, Luke ​made headlines when he went on ITV’s This Morning to discuss his HIV status. “I never heard anything about HIV in school,” he said. “You can become a bit reckless when you come of age, but it’s far worse if you have no basis of knowledge to refer to.”

Like James, Luke’s ​sex and relationship education in school was virtually non-existent. “It lasted a few hours. If people weren’t there, they didn’t receive it. While they stressed the importance of contraception, it was for pregnancy. When I asked about anal sex, they said, ‘We don’t recommend it.’ I felt embarrassed. I just wanted to hear their perspective.”

Harris agrees that the education system has failed in this regard, saying that:

“Young gay men are generally frozen out by the current approach to sex education in schools.”

“The past is the past, though, and you can’t change that,” James reasons. “The great thing now is I’m healthy and happy. I’ve been on meds for five years now and doing so well. My health, in general, is alright.”

But living with HIV isn’t just about monitoring your physical wellbeing. The emotional strain of the constant check-ups and coming to terms with the virus can also present its own psychological strain.”Physically I’m fine,” James says. “I do suffer with depression, but that’s down to several things—not just my HIV. Sometimes it’s difficult juggling lots of meds every day. Often my depression gets bad and tells me I’m worthless and to not take it. But I have faith in medicine that one day there will be a cure.” His biggest wish is more altruistic still: “More knowledge and understanding around HIV and AIDS.”

For many recently infected guys, getting their head around living with HIV is one of the biggest challenges. Stigma is a major issue.

“Robert,” 29, (not his real name), has been HIV positive since 2007. A casual partner sexually assaulted him when he was passed out after a heavy drugs session. Only his closest friends and immediate family are aware of his status. He puts this down to the assumptions that people make about those who are positive. “It’s not the fact that it’s an unattractive quality [to be HIV positive], it’s that people think you had a choice. You hear a lot about bareback parties and people who think that those who have a lot of condom-less casual sex ‘deserve’ to get HIV. I don’t judge anybody but I don’t want to be put in that category. I’m not ashamed of being HIV positive, but it does affect how people perceive you if they don’t know you.”

Robert has told around ten partners about his status when they’ve asked about barebacking. “I don’t have unprotected sex unless we are both aware of our status,” he says. Even so, he says it’s still common for HIV positive guys to be afraid to disclose their status to others in the same position: “I’ve even met positive guys who I’ve been honest with, but they have lied about being positive because they don’t want to say they are.”

It’s upsetting to think that we are forcing so many thousands of gay men into a situation where they feel alienated by their own community. It takes a strong person to rise up against a tide of possible condemnation and be among the first to speak up.

Luke lost friends after going public about his diagnosis. People stopped answering his calls. He believes it was because they were afraid to be associated with somebody that was openly HIV positive. Similarly, when he confided in a friend about his status, she was more concerned that she’d shared his wine glass than how Luke was feeling. (Incidentally, if you labor under similar misconceptions, HIV cannot and ​will not be spread by sharing glasses.)

Sadly, despite it now being considered to be a very manageable long-term health condition, HIV is still widely misunderstood. “You can sit on a park bench and talk for two hours with someone about your diabetes,” Luke says. “But you can’t do that with HIV because you’ll often get a look of fear and shock.”

Niyi eventually reached a point when he had enough of feeling ashamed. “I woke up one day and was like, life isn’t always going to be easy. Self-pity isn’t fierce and it isn’t fun. Doing things and being around people that encouraged me to feel good about myself was such a big help.”

There is one hurdle that remains for him, though, and that’s relationships. He’s been single for seven years. “The thought of being rejected by a guy because of it terrifies me. I feel that it will always hold me back until I am able to get past that final fear.”

James has been luckier in love. He met his boyfriend 18 months ago and they married last August.

Niyi, Luke and James are heroes!  They have decided that it’s time to challenge the stigma that looms around HIV for no other reason than people are not talking about an issue that affects us all. The education system is broken, so they’ve taken it upon themselves to speak out about it. They have taken a situation that could have stripped them completely, that could, if they let it, absolutely define them, but instead have turned it into something powerful.

As his fears subsided, Luke was inspired by another HIV activist and started blogging about his experience. “It got a lot of attention. I wanted to help people understand and it was a feeling of empowerment. The good reactions that followed confirmed it was the right thing to do,” he says. He now also writes monthly about the subject for Gay Times.

Niyi agrees. “There are so many people suffering unnecessarily because they feel that being HIV nullifies everything good about who they are, but it really doesn’t. Everybody deserves to wake up feeling like they are of value and if all I have to do is talk about my situation in order for people to see that, then that’s what I will do. People need to know that someone’s HIV status is not an indication of what kind of person they are.”

Story via Vice

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HIV in the UK: 76% diagnosed, 90% on treatment, 90% undetectable

UK achieves two out of three UNAIDS targets, but undiagnosed infection remains a major problem

The UK’s annual epidemiological report, released yesterday, shows that the country already provides HIV treatment to 90% of people attending clinical services and that 90% of those on treatment have an undetectable viral load. But the country has a long way to go in ensuring that people with HIV are aware of their HIV status – only 76% of people living with HIV have been diagnosed. The problem is particularly acute in black African communities, as only 62% of African heterosexual men and 69% of African heterosexual women living with HIV have been diagnosed.

The figures can be compared to the ambitious targets announced by UNAIDS (the Joint United Nations Programme on HIV and AIDS) earlier in the year: for 90% of all people living with HIV to know their status, 90% of those to be on treatment and 90% of those to have an undetectable viral load. If these figures could be achieved by 2020, the global AIDS epidemic would be over by 2030, UNAIDS said.

The UK appears to have achieved two out of three of the targets, but has a significant problem due to the high rates of undiagnosed infection. Overall, 61% of all people living with HIV in the UK have an undetectable viral load. This contrasts with the 73% that would be achieved if all three of UNAIDS’ 90/90/90 targets were accomplished.

New diagnoses, overall prevalence

Public Health England reports that 6000 people were newly diagnosed with HIV in the United Kingdom in 2013. The overall figure is lower than that seen a decade ago, due to fewer diagnoses among heterosexual men and women born in high-prevalence African countries. Among gay men, the number of diagnoses is as high as ever, with 3250 cases reported in 2013. An estimated 30% of the gay men diagnosed in 2013 were recently infected with HIV (within six months of their diagnosis).

There are now almost 110,000 people living with HIV in the country, including 26,000 who don’t know they have it. This can be broken down into risk groups:

• Gay, bisexual and other men who have sex with men (43,500 people; prevalence of 5.9%).
• Black African heterosexual women (25,100 people; prevalence of 7.1%).
• Black African heterosexual men (13,600 people; prevalence of 4.1%).
• Heterosexual women of other ethnicities (10,300 people; prevalence of 0.06%).
• Heterosexual men of other ethnicities (10,200 people; prevalence of 0.06%).
• People who inject drugs (2400 people; prevalence of 0.7%).

High rates of undiagnosed infection, especially in black African communities

Overall, 24% of people living with HIV are unaware that they have it. The rates of undiagnosed infection are lowest among gay men (16%) and people who inject drugs (10%).

In relation to black African people, it’s worth noting that in previous epidemiological reports the description of a person as ‘black African’ primarily depended on whether they were born in an African country. In contrast, the new report focuses on a person’s ethnicity, so that someone born in the UK to Nigerian parents is considered in the ‘African’ category. As a result of this and other methodological changes, some of the figures for undiagnosed infection are not directly comparable to previous years’ – and paint a more worrying picture.

In 2013, 31% of black African heterosexual women and 38% of black African heterosexual men who had HIV were unaware of their infection. Rates of undiagnosed infection were somewhat lower among heterosexual people of other ethnicities: 27% in men and 23% in women.

The report also shows that rates of undiagnosed infection are far worse outside London, compared to the capital. Outside London, 41% and 49% of African men and women were undiagnosed. In London, 10% and 13% were undiagnosed. There is some fuzziness to these estimates: the true values could be up to 10% higher or lower than the figures given here. But a clear geographic difference would still be observed. This could reflect stronger community networks and more accessible health services, including targeted prevention, in the capital.

Another way to consider undiagnosed infection is to look at rates of late diagnosis – people diagnosed with a CD4 cell count below 350 cells/mm³. Rates of late diagnosis were highest among heterosexual men (62%) and heterosexual women (51%), with black Africans especially likely to be diagnosed late. The lowest rate of late diagnosis was seen in gay men (31%). Across all groups, older people and non-Londoners were more likely to be diagnosed late.

But progress has been made over the past decade – the overall rate of late diagnosis has gone down from 57 to 42%.

A higher uptake of HIV testing, including more frequent testing, is needed to improve the figures on undiagnosed infection and late diagnosis. The report shows that, at sexual health clinics, 86% of gay male patients take an HIV test, but only 77% of heterosexual men and 67% of heterosexual women do so. Whereas guidelines recommend that all people attending sexual health clinics are offered an HIV test, only one-in-seven clinics test at least 80% of their heterosexual patients. Public Health England recommends that clinics review their policies and training protocols.

But while PHE has been able to collect data on HIV testing in sexual health clinics, none are available for testing in GP surgeries, in other medical settings, or in community settings. A significant improvement in the proportion of people living with HIV who are diagnosed is thought unlikely to occur without improved provision of testing in non-specialist settings, as recommended in guidelines. The report notes that less than one in five of the black-African population attended a sexual health clinic in the previous five years.

“Reductions in undiagnosed infection can be achieved through increasing testing coverage in STI clinics, the introduction and consolidation of HIV testing in a variety of different medical services, in addition to further development of community testing, including self-sampling,” PHE comment.

Quality of care for people living with HIV

Considering the next stages of the ‘treatment cascade’ and the National Health Service’s performance in relation to UNAIDS’ targets, the report shows that 90% of people were linked to care within a month of their diagnosis (98% within three months). Moreover, 95% of those who received care in 2012 were retained in care in 2013. Results did not vary according to age, gender, ethnicity, sexuality or geographical area.

Further, 90% of people in care received antiretroviral therapy (up from 69% in 2004). This includes 92% of those with a CD4 cell count below 350 cells/mm³. Of all people taking treatment, 90% had an undetectable viral load, below 200 cells/ml.

Generally there was equality in treatment outcomes, although younger people were less likely to be taking therapy. Moreover, people in both the youngest (15-24 years) and the oldest (over 50) age groups were less likely to have an undetectable viral load.

Guidelines recommend that clinicians discuss treatment as prevention with patients, and give them the option to start treatment early for this reason. Probably as a result, average CD4 cell counts when starting treatment have risen in recent years. In 2013, 25% began treatment with a CD4 cell count between 350 and 500 cells/mm³, and a further 26% did so above 500 cells/mm³.

Article via NAM

For your full copy of the report, click here

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Human Genome Tinkering Could Be Our Best Bet to Beat HIV

The human immunodeficiency virus (HIV) is a crafty little beast, constantly mutating to mask itself from our body’s defenses, but always entering cells through the same molecular door. The design of that cellular door is governed by our DNA, so why not change the lock by modding our genetic code?

In 2006, a minor medical miracle occurred. HIV-positive leukemia patient Timothy Ray Brown—the second Berlin Patient—received a bone marrow transplant that saved his life in more ways than one. The marrow that he received was from a donor with a unique double mutation to a gene on the 3rd chromosome known as CCR5. This gene codes for the surface protein that the HIV virus uses to gain entry into our white blood cells (specifically, CD4+ T-cells); however the double mutation shuts down these sites and provides a natural immunity to HIV. This mutation is exceptionally rare, only occurring in about one percent of Caucasians and nowhere else. It’s been hypothesized that it’s this same natural immunity that allowed a small portion of Europeans to make it through the Black Plague unscathed.

While that was fantastic news for Brown, who nearly a decade later remains off of his retroviral drug regimen and maintains an undetectable level of the virus in his system, it’s not of much use to the rest of us. With both the mutation prevalence and bone marrow compatibility matches in general being so rare, there was no effective means of using transplants as delivery vectors for this beneficial genetic condition. And it’s worth noting that the very process of becoming HIV-free nearly killed Brown. But that’s where Professor Yuet Kan’s team at UCSF comes in.

Kan figured that if integrating this double mutation wouldn’t work on the macro level—that is, replacing a patient’s bone marrow with that of a naturally HIV-immune person’s—maybe it would at the molecular level, thereby allowing researchers to confer the benefits while cutting out the marrow donation. To that end, he and a team of researchers from the University of San Francisco are employing cutting-edge genetic editing techniques to snip out the beneficial length of DNA coding and integrate it with a patient’s own genome.

The technique they’re using is known as CRISPR (Cas9) genome-editing. CRISPRs, (clustered regularly interspaced short palindromic repeats) are DNA delivery vectors that replace the existing base codes at a specific part of a specific chromosome with new base pair sets. Cas9, on the other hand are the “molecular scissors” that Kan’s team employs to first cut out the offending DNA. It sounds easy, sure—just find the string of DNA you want to replace, then snip it out with Cas9 DNA scissors, and install some new DNA using a CRISPR—however the nuts and bolts of the process are far more technically challenging.

The patient’s own blood cells would be employed as a precursor. Researchers would then have to convert those cells into induced pluripotent stem (iPS) cells by modulating a number of genetic switches, thereby instigating their regression to more basic stem cells. After that, the offending CCR5 gene would need to be knocked out and replaced with the better, double-mutated version before the now fortified blood cells were transfused back into the patient. Not only is there no chance of the body rejecting the new cells (they are the patient’s own after all), the technique also neatly sidesteps the whole embryonic stem cell issue.

While the technique is still in its early stages of development and no human trial dates have yet been set, it holds huge promise. Not just for the 35 million people annually infected by HIV, but also sufferers of sickle cell anemia and cystic fibrosis—two deadly diseases caused by a single protein deformation—could benefit from similar techniques. By figuring out which genes do what on our iPS cells, we could even theoretically grant everyone on Earth immediate immunity to any number of diseases.

Of course, being able to update and augment our genetic code opens up a whole slew of potential concerns, objections, and abuses. Just look at the ire raised over the use of embryonic stem cells in the early 2000s. People were lost their minds because they thought scientific progress was being built on the backs of fetuses. Researchers had to go and invent an entirely new way of making stem cells (the iPS lines) just to get around that one moralized sticking point, so you can bet there will be plenty of chimera, master race, and Island of Dr. Moreaureferences bandied about should we ever begin seriously discussing the prospect of upgrading our genes. And could certainly slow progress in this specific research.

That’s not to say that the hysteria that accompanies seemingly every news cycle these days is completely off base. Like cars, styrofoam, pressure cookers, and thermonuclear bombs, this technology can be used for evil just as easily as it can be for good. And while we’re not nearly as genetically complex as, say, an ear of corn, wrangling the myriad of interactions between our various genes is still an incredibly complex task and one with severe consequences should something go awry—even if we can avoid creating unwanted mutations through stringent testing and development methodology as we do with today’s pharmaceutical development. So why not turn ourselves into the ultimate GMOs? It certainly beats everyone becoming cyborgs.

Article via Gizmodo

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