PrEP as Prevention

‘Give HIV meds to healthy gay men’ was the title of a BBC article on Tuesday this week. The reason for the attention grabbing title was the publication of results from the groundbreaking UK study into PrEP were released on Tuesday at the Conference on Retroviruses and Opportunistic Infections in Seattle. The so-called PROUD study, based on data from 545 participants, showed that PrEP is highly effective at reducing HIV transmission. In the study truvada (an antiretroviral drug) was given to MSM who have had unprotected sex in the three months before enrolling and who were likely to do so again and after 12 months the results were compared for those who were on PrEP and those that weren’t. The group given the drug showed a reduced risk of HIV transmission of  86%. This meant that there were 1.3 new infections per 100 person-years in the group given PrEP immediately, and 8.9 per 100 person-years in the group who were not taking on PrEP. Those who were recruited had an average of 10 partners in the last 90 days .Perhaps the most notable thing about the study results is that they represent the highest efficacy rate of any large scale trial to date, bringing hope that the drug may be approved for use in the UK soon. Sheena McCormack, Professor of Clinical Epidemiology at the MRC Clinical Trials Unit at UCL, and Chief Investigator of the PROUD study, commented:

“These results are extremely exciting and show PrEP is highly effective at preventing HIV infection in the real world. Concerns that PrEP would not work so well in the real world were unfounded. These results show there is a need for PrEP, and offer hope of reversing the epidemic among men who have sex with men in this country. The findings we’ve presented today are going to be invaluable in informing discussions about making PrEP available through the NHS.”

Image from the PROUD study website

Based on the results of the potentially game-changing study PrEP is shown to be an important option for high risk men who are unable to consistently practice safer sex. Obviously there are questions of cost-effectiveness which will have to be answered before PrEP becomes available on the NHS, but it is likely that soon the UK will follow the US and make PrEP available as one tool to prevent new HIV infections. What do you think about using PrEP to prevent HIV transmission? Do you think this is the right approach to reducing HIV infections in the UK?

Hip-hop HIV prevention

This evening, for one night only, we are starting the weekend with a special outreach session at The Place. We are there in partnership with the 201 Dance Company who are presenting their latest production ‘If you leave’. It is a beautiful story of a same-sex relationship and will be part of the Resolution 2015 festival. It is raw, cutting-edge hip-hop with a homosexual twist. We will be there with a supply of sexual health leaflets and other goodies, ready to talk about any of the issues raised in the piece and to make referrals to relevant sexual health and wellbeing services. So, what are you waiting for? If you’re in London tonight why not come down, have a chat with GMI’s very own Rob and Tony, and enjoy the show! We’re there from 7-10pm, and full details of the event can be found here.

Scaring into Safe Sex

When you ask people what sort of HIV prevention campaign is effective, by getting people to test and reducing risk taking behaviours, most people say something shocking is needed – like the falling tombstone used in the UK adverts of the 80s below. But, it this really the best approach, and what are the arguments for and against trying to scare people into having safe sex?

The very fact that most of you reading the blog can recall the tombstone advert seems to demonstrate one advantage of such an approach – done properly it can be extremely memorable, and can attract lots of attention, and really get people talking about HIV. In addition, there is evidence that if someone feels they are equipped to make behavioural changes necessary (whether physically or psychologically) then there is some evidence that this type of approach might have a successful impact. However, the flip side is that such individuals are more likely to already be engaging in safer sex and test frequently anyway, and are (in many ways) not the most useful group to target with HIV prevention messages. In addition, crucially, those that are ‘less well-resourced’ to negotiate safer sex may actually ‘feel even worse when confronted with fear-arousing messaging’ and they might result in feelings of anger or defensiveness which can actually result in unsafe sexual behaviour (see a Sigma report on fear and HIV prevention here for more info).

Other potentially serious consequences of fear based approaches is that they can result in othering of people with HIV and actually increase discrimination as the fear of the virus is transferred to those that have HIV. It can also increase anxiety about HIV which research shows is one of the main barriers preventing people from testing. In addition, there is evidence which shows that fear only translates into behavioural change when people are not fearful, and data from the Gay Men’s Sex Survey shows that most gay men are still HIV and view it as a serious illness. In conclusion, while inducing campaigns can make people more scared of HIV there is little evidence that this would encourage people to make behavioural changes necessary to reduce risk, or increase testing, particularly those that might be seen as most at risk groups.

It is likely that for these reasons HIV prevention campaigns have become less shocking in the last couple of decades. The poster above shows a current campaign by HPE in the UK using the tagline ‘It starts with me’ . Similarly, in New York where HIV prevention campaigns have traditionally been fear-arousing (such as the shocking 2011 NYC department of health advert which included a close-up photo of anal cancer, see here), there has been a move away scare based approaches. For example, the latest HIV prevention campaign by the NYC department of health uses the phrase ‘Be HIV sure’. Dr Daskalakis, who is behind the campaign, claims that its aim is to focus more on health and less on disease. This change in city-wide approach is supported by others working in HIV in New York, such as Terri Wilder of ACT-UP . These ‘softer’ approaches seek to increase knowledge and empower people to make informed decisions through positive terminology, rather than scaring people with explicit imagery and negative wording.

What do you think HIV prevention campaigns should look like? Are dramatic images and shocking phrasing effective, or do you think they are counter-productive?

The views in the article are those of the author and do not necessarily represent those of the GMI Partnership. The GMI Partnership provide rapid HIV testing and outreach work across London. For more information please see their website.  

Merry Christmas and Happy New Year

Is it just us or has 2014 flown by?! Here at GMI we have been busier than ever over the last year – we are now working in every LGBT venue across London (including bars, clubs, sex venues and special events) and testing in more places than ever before. We would like to take this opportunity to say thank you to all the venues, organisations and service providers that have supported us in our HIV prevention work throughout 2014. In addition, we would like to thank all of our service users who have tested with us, or come to GMI for advice and information.

Our opening hours at each of our partners over the Christmas period are as follows:

Metro Centre: Closed Christmas Eve 12 noon, open 9am Friday 2nd January

Positive East: Closed Chistmas Eve 12 noon, open 9am Friday 2nd January (NB – no testing until 3rd January)

West London Gay Men’s Project: Closed Christmas Eve 12 noon, open 9am Friday 2nd January

Finally, we would like to wish all of our readers a  Merry Christmas and Happy New Year! We’ll be back in January, for what is already shaping up to be an exciting year!

Prepared for PrEP

What is it?
PrEP, or pre-exposure prophylaxis, is HIV medication that is taken by people at-risk of exposure to HIV. In the US it is already available and is marketed as ’Truvada’ ( emtricitabine and tenofovir disoproxil fumarate).

Is it available in the UK?
In the UK it is not currently available, but this is likely to change in the near future. PrEP is currently being trialled here in the UK under the PROUD study, where it has been shown to be highly effective. There is currently an NHS England process underway to evaluate PrEP, although this is unlikely to be implemented until 2017. Given the effectiveness of PrEP in previous and current studies we would suggest that procedures should be brought into force as soon as possible that would allow those most at risk to start taking PrEP while the evaluation is ongoing.

Does it work?
Overall, studies show that PrEP is effective at reducing HIV transmission. Indeed, the UK PROUD study and European IPERGAY studies were so effective that everyone in these studies has been offered PrEP. It was viewed unethical to give placebo as a comparison because of this. While research generally shows high efficacy, this varies between study. A study published in 2012 (as part of the iPrEx trial) showed efficacy rates of 99% when PrEP was taken daily, although this fell to 76% when taken twice per week. This study is one example which demonstrates the importance of adherence to treatment for PrEP to be effective. Although figures for the PROUD study have not yet been published they are also likely to also show a high level of efficacy

Who would take PrEP?
When PrEP is approved in the UK it will be taken by those who are at high risk of seroconverting (becoming HIV positive). This would include three main groups: 1) serodiscordant couples 2) people who are unable to insist on condom use, and 3) other high risk populations such as injecting drug users.

Do we really need PrEP?
PrEP is a vital addition to the toolbox of HIV prevention strategies. It can allow those unable to consistently engage in protected sex to reduce the risk of HIV transmission. It can also be used when needed to match changing sexual behaviour. However, for PrEP to be effective (and especially to encourage adherence) it must be part of a wider HIV prevention strategy focused on behavioural approaches (e.g. counselling and one-to-one work).

PrEP Statement
In November 2014 a joint statement on PrEP was issued by community organisations working on HIV prevention, including the GMI Partnership organisations (Metro Centre, Positive East and West London Gay Men’s Project). The statement outlines the need for PrEP, gives information on its efficacy and, speaks to commonly highlighted barriers to the introduction of PrEP. Importantly, the statement also demonstrates that there is an emerging consensus amongst sexual health and HIV charities that PrEP is supported across the field. It also represents an attempt to collectively lobby for action, including for the immediate provision of PrEP for most at risk populations.

For more information on PrEP please see the Aidsmap website

To arrange a drop-in, rapid HIV test at a time that is convenient for you please call GMI Partnership on 020 7160 0941.

DIY HIV Testing

On April 6th this year self-testing HIV kits were approved in the UK, following a government amendment to the law, and within the next few months it is likely they will be available to buy over-the-counter for the first time. So, what is a self-testing kit?

A self-testing kit is a do-it-yourself test for HIV which uses saliva or a blood sample to provide an instant result. It is different to a home sampling/screening test where the test is done at home and then sent away for laboratory analysis, normally providing a result within 3-5 days.

Currently self-testing kits are not yet on sale in the UK and no companies have applied for a license to sell self-testing kits within the EU, even though they are now legal here. When they are finally on sale they will carry the CE mark to show they can be used safely.

What are the advantages of self-testing for HIV?

Reaction to self-testing kits has been largely positive, as reflected in this comment by a spokesperson for the Royal Pharmaceutical Society, who said “”HIV self-testing kits may help increase diagnosis by providing more choice for people who have been at risk but are reluctant to get a test in person from existing services.”

Convenience: There is no booking appointments, no waiting times and no going to the clinic so self-testing is a convenient way to do an HIV test.

Privacy: Doing the test from your home is private and anonymous and you don’t need to talk to anyone about doing the test, which might be preferable for some people.

For these reasons it is possible that self-testing will increase the likelihood that those who have never tested/test infrequently know their HIV status and, as a consequence their use could result in a drop in undiagnosed HIV cases and late diagnoses.

Are there any disadvantages?

Cost: Self-testing kits need to be bought and aren’t available for free like home sampling/screening tests.

Support: When testing at a clinic or pop-up testing service you speak to a trained advisor who is able to have a pre-test discussion, answer any questions and signpost to appropriate services.

Misdiagnosis: There is some worry that people who don’t understand the test might misinterpret the result, although there were similar concerns about pregnancy testing and this is now commonplace.

Other ways to test:
Self-testing and home sampling are great additions to current testing options, but are not appropriate/preferable for everyone.

The GMI partnership offer drop-in and pop-up testing across London. For more information please call 020 7160 0941 or e-mail tony@metrocetnreonline.org

If you would like to find your local GU service place see the NHS website here.

In addition the Metro Centre (Vauxhall and Greenwich), Positive East (Stepney Green) and West London Gay Men’s Project (Ladbroke Grove) in London also offer free HIV testing. Please click on the organisation for more information.

NB – If you have had unprotected sex in the last 72 hours (and there is risk of HIV transmission) it is possible to take Post-exposure prophylaxis (PEP) to reduce the chance of transmission. PEP can be obtained from and sexual health clinic or accident and emergency department.

Gaycon 2014

Last week saw the 5^th Scottish Gaycon. That’s the Scottish conference on sexual health of gay and bisexual men to you and me. The GMI partnership was present, through a representative from one of our partners, the Metro centre. It was a great event with over 200 delegates came together to participate in workshops, discussions, presentations and workshops, which allowed us to share innovative practice, discuss current research and think about key priorities for those working in the field of MSM sexual health. Although a wide-range of topics were discussed over the two days some of the key notes are summarised below in the notes made by our representative:

Epidemiological data 

• UK and Scottish data showing an increase in STIs over the last decade, with a possible flattening over the last few years (Scotland but not England) although too early to tell if this is a pattern.
• New diagnoses of HIV are increasing slightly, predominantly amongst MSM.
• The UK has the highest rate of those diagnosed with HIV in care in the world – 96%, this is even more impressive north of the border, 98% (and has been slowly increasing over the last decade).
• As would be expected HIV and STI rate are higher in urban centres e.g. central belt, compared with rural areas.
• Late diagnosis is still a key barrier, although there has possibly been a slight decrease from 40% ’04 to 35% ’14 (Scottish figures).
• Emerging problems: gonorrhoea resistant to treatment, HEPC and co-infection with HIV and other STIs.

TasP (Treatment as Prevention ) and PrEP (Pre-exposure prophylaxis)

• May ’14 CDC guidelines updated regarding PrEP and WHO now recommends it as ‘an additional HIV prevention choice’. European Disease Control (EDC) not recommended it yet.
• iPrEX study and others have shown that PrEP can be extremely effective, although it is not 100% effective, largely for reasons of adherence.
• Consensus of the urgency of being prepared for the introduction of PrEP, especially now the Proud study has been fast tracked due to the high efficacy of PrEP with the first group of participants.
• 48% of MSM said they would use PrEP (SMMASH study), 30% of HIV negative men have heard of PrEP.
• Awareness of PrEP is much higher amongst positive men (75%) than negative men (30%), and higher amongst cities compared with rural areas.
• But most data considers barriers to PrEP is from the US – There is a lack of data from elsewhere and most data focuses on willingness to take PrEP, rather than exploring why or how.
• Focus group data on perceptions of PrEP by Dr Ingrid Young – Glasgow University: interpreting effectiveness (and concern that not 100% effective) managing adherence (establishing a routine, social barriers and side effects), low perceptions of risk, moral concerns (that others would stop using condoms, irresponsible decision).
• Trust of community regarding trials appears to be a factor in certain instances e.g. VOICE study efficacy much lower compared with iPrEX trial.

 

Home HIV testing

• In a hand poll, everyone present agreed that home testing for HIV could be a successful part of an HIV prevention strategy, the question then, appears to be on the specific approach taken.
• Self-testing can help normalise testing, reach the unreachables and reduce late diagnoses, as well as increasing testing numbers (e.g. SMMASH study: 29% of high risk men have never tested).
• THT Scotland data showed 62% of HIV negative respondents said they would be more likely to test for HIV if they were available – awareness that this might not mirror real behaviour.
• Effective self-test return rate: 75% returned in Scotland to THT amongst MSM (although lower return rates for BME communities. This raises questions about which approach is best for different communities.

 

Online prevention

• Need for more sharing of ideas about what works for a successful online HIV/STI prevention approach, including online sexual health outreach and promotion.
• Online health promotion brings possibilities of varied, interactive and tailored approach on unique sexual cultures.
• Need to recognise that MSM who use online sites + apps , are different to those who are out on the gay scene g. SMMAASH study data: MSM on the gay scene testing more and having less unprotected sex compared with men online., 42% men surveyed online never socialise on the gay scene., 37% have never tested for HIV.
• Passive outreach more acceptable than active, but this maybe throws up more questions than it solves i.e. why is this the case? What sort of active approach would be more acceptable?
• Professor Paul Flowers: Importance of taking a sexual and social network approach to HIV/STI prevention, rather than focusing on the physical space of the gay scene, including better understanding and awareness of the use of apps.
• Networks is one way of using social media to deliver sexual health promotion e.g. reaching and targeting very specific communities – it is useful to be more savvy about this and to use online resources innovatively and to their full potential.
• SMMASH study shows gap between available apps and complexity of relationships that looking for, inequalities of online access e.g. money for internet, smartphones etc.
• For recruitment: banner adverts not affective, shout outs were.

Working with those with disabilities

• Little attempt to target HIV/STI prevention approaches, or even tailor them, to those with disabilities.
• Literacy, lack of autonomy perceived asexual + perpetual child status are big barriers to doing this, which must be tackled.
• Research review by Alan Middleton – Glasgow Cali: knowledge following interventions increased, but lost if practical skills not appropriate.
• Individual (literacy, internalised discrimination, understanding feelings/relationships, travelling independently, lack of role models), social (lack of autonomy, disabledism) and organisational barriers (geographical, pace of groups etc.) pervasive.

Effective sexual health interventions with BME communities

• Godwyns – Justice for Gay Africans: Family honour is hugely important for African communities and this must be recognised by those providing HIV prevention services.
• SAAM Scottish African MSM study: religion, identity and immigration are key barriers to engaging Africans in sexual health.
• Importance of acknowledging the difference of MSM and gay/bisexual male communities and their needs. E.g. in SMMASH study MSM are older, have less unprotected sex and test less frequently than gay and bisexual identified men –the challenge is recognising these differences and ensuring that the needs of these different communities are met.
• Importance of fairer policy discussions (involving and empowering BME communities), targeted outreach (establishing trust and respect of cultural background).

 

Decisions, decisions…Finding the right condom

If I remember to put a condom on that’s enough isn’t it? Well, with sexual health messages focusing on the importance of putting a condom on, it can be easy to forget that it is also crucial to find the right condom for you. Condoms come in all different shapes, sizes, textures, colours and flavours and finding the correct one is important, both in terms of keeping safe and enjoying the sex you are having!

Size

Condoms come in all different lengths and sizes, to reflect the fact that, guess what, so do our penises! There isn’t one standard size of condom, although availability and names of different sizes may vary depending on where you are (pharmacy, charity, clinic etc.). A good place to start might be the theyfit website. They have condoms in, wait for it, 95 different sizes!

Thickness

Questions about whether you need to use a thicker condoms for anal sex are commonly heard by our outreach workers. The answer actually no (as there is no significant difference in failure rates), but some men and their partners prefer using thin, or ultra thin condoms to improve sensation. Others prefer thicker ‘delay’ condoms which do the opposite and reduce sensation.

Lubricated or non-lubricated

Whether you’re having anal or vaginal sex you might prefer to use a pre-lubricated condom. Some men would rather use a non-lubricated condom and use their own lube (see note below!). When having anal sex (in particular) using a lube can make the sex safer, as it reduces the risk of condom breakage, and can make it more pleasurable too.

Latex or non-latex

Most condoms are made from latex. If you or your partner has an allergy to latex, or even if you don’t like the feeling of latex condoms it might be an idea to try non-latex condoms. Some men and their partners prefer the feeling  of these condoms saying that they give a more ‘natural’ feel.

Texture

What we like the feeling of is quite subjective, but whatever feels good there are condoms out there to match. You can find ribbed, bumped, groove and studded condoms to name but a few.

Flavoured and coloured condoms

Condoms can be found in all different flavours, including some you might not expect. I can’t imagine whisky condoms selling as well in England as they do north of the border. You can also find different coloured and even glow in the dark condoms, as well as themed condoms like Halloween and Christmas!

So, now you’ve chosen the condom you want to use, but how do you put it on? This handy poster produced by AVERT explains in 3 easy steps:

Remember, use a water based lube, as oil based (e.g. Vaseline/baby oil etc.) can break  latex condoms. And, finally, putting on a condom doesn’t have to disrupt the mood – many men include putting on the condom as part of foreplay and ask their partners to do it for/with them!

Check out the Freedoms website for more information on condoms and to order them, right to your door! For more information on the HIV prevention work we do across London please see our  website . 

Why the US model doesn’t work: HIV treatment across the pond

In some ways the US can be thought of as advanced in terms of HIV. Research into vaccinations and trials of new medications, as well as the roll-out of PrEP, put the country ahead of many others when it comes to establishing pioneering biomedical approaches to HIV prevention. But, in other ways they have set a precedent that other countries would do best not to follow.  One of these, it could be argued, is the approach to HIV treatment. This can be seen most clearly when looking at what is called the treatment cascade.

The treatment cascade shows the drop off in people living with HIV compared with people receiving care, on medication and accessing treatment. Looking at the graph below the difference in these figures for the UK and US are striking. Whilst both have almost the same numbers of individuals living with HIV and are aware of their status (77% and 79% respectively), numbers for those in treatment are very different.  In the UK, the majority of people living with HIV are: in care (73%), on treatment (64%) and have an undetectable viral load (58%). In the US, less than half of people living with HIV are in care (44%) and only a shockingly  small proportion are on treatment (24%) and have an undetectable viral load (19% – 3 times less than in the UK).

A significantly lower proportion of people living with HIV are accessing the care that they need or on anti-retroviral medication in the US compared with the UK. The results of this on physical and mental health, as well as transmission, cannot be overstated and can be seen in the higher rates of HIV across the pond. HIV prevalence in the US  is about 3 times that of the UK. Thos is just about the highest of any ‘developed’ country (0.6% in US vs. 0.2% in UK). But why is this? Well, they key reason is that HIV medication in the States is not free, except for the very poorest, and to access anti-retrovirals you must have health insurance. While in the US generally only about 15% of people don’t have medical insurance, less than 20% of people living with HVI have private medical insurance (see here) . Delaying treatment has health consequences for the individual and increases the onward risk of transmission, which in turn have financial implications which make the treatment of HIV much more expensive and costly for society as a whole. For these reasons, the US approach to HIV treatment could be described as unacceptable, and many would argue shameful, particularly for such a rich country.

Whilst the UK has a much higher proportion of people with HIV in services and on treatment (arguably world leading, in fact) this doesn’t mean that we should rest on our laurels. Rather, those working (see paper by Professor Jane Anderson see here ) in HIV argue that we need to focus on better understanding the reasons why there is a treatment cascade in the UK and work to overcome barriers to accessing treatment and care. This involves asking why the UK figures are not closer to 100%. Stigmatisation when using and accessing services, barriers to service access, societal discrimination, problems affecting treatment adherence and knowledge and understanding of HIV transmission and treatment are all issues that require more research with concrete changes at service delivery if further progress is to be made. Thus, while the UK’s approach to HIV treatment is admirable, in many ways, there is still work to be done to ensure HIV rates are reduced and treatment is more effective.

In the zone!

If you follow our blogs you’ll be aware that we do pop-up, rapid HIV testing across London. We offer completely free testing using the finger prick test and the result is instant (well, about 30 seconds to be precise!). Currently our testing happens at regular sessions at Ku Bar – Lisle Street, Chariots Saunas (Waterloo, Streatham, Vauxhall and Limehouse) and  Expectations – Old Street, the Lockeroom and Pleasuredrome, and you can see the full list of locations we do information and testing sessions on our website. These sessions are extremely popular as they allow us to reach people who might want to, or might not have the time to test in a clinic. We bring the testing to you with trained staff and volunteers who test in confidential spaces at each location.

We are excited to announce that tomorrow we will be doing a special one-off session at Clone Zone, Old Compton Street, Soho from 6-8pm. So, while you’re doing your shopping you can conveniently also do a rapid HIV test, ask us any questions you might have about your sexual health, or even pick up some condoms and lube.  We’ll be upstairs at the back of the shop, so be sure to pop in if you’re about in Soho tomorrow evening!