The title quote was written by George Bernard Shaw in ‘Saint Joan’ in 1923 but if ever a saying is timeless it’s this one.

The reason I’m dragging it out of the cliché locker is because I feel I have to take issue with a couple of articles that have appeared on PositiveLite.com recently.  

They are IS HIV TRANSMISSION POSSIBLE WHEN VIRAL LOAD IN THE BLOOD IS UNDETECTABLE? from CATIE and INFECTIOUSNESS coming from Aidsmap.com

I respect the work that people in HIV organisations put in to the struggle to control the virus and I appreciate the time and effort put in by writers who do their best to provide us with information – we’d be in a sorry state without them. I also know the perils of one article writer criticising another but I genuinely mean no disrespect. These two articles are pretty representative of what you will find all over the net and therefore my problem is more with the genre than the individual articles themselves.

The CATIE article addresses a question which is in the back of everybody’s mind. It’s crucial, both for positive and negative sex partners. The title suggests that the question will be answered but unfortunately that’s anything but the case. The first paragraph sums up what viral load actually is but hardly gives hard and fast rules which we can hang our hats on. It talks about the viral load being measured in the bodily fluids of a positive person. Surely it’s not. It’s measured in the blood and only very rarely in semen, saliva etc.

“Research shows that successful HIV treatment can reduce the viral load to “undetectable” levels and this can reduce the risk of HIV transmission. However, HIV transmission may be possible when the viral load is undetectable…The risk of HIV transmission when taking antiretroviral treatment may increase if sexually transmitted infections (STIs) are present…This risk may also be higher for anal sex than for vaginal sex.”

What do they mean, ‘can’ and ‘may’? We’re thirty years into the history of the virus. We should be hearing ‘does’ and ‘will’, not bet-hedging to cover all possibilities!

The following is something we’re all very aware of but what does a statement like this actually tell us?

“Viral load tests used in Canada cannot detect HIV in the blood if there are less than 40–50 copies/ml. Therefore, an undetectable viral load means the amount of virus in the blood is too low to detect, it does not mean that there is no virus present.”

First of all, we know the testing procedures are still limited but surely we’re entitled to ask why? Secondly, what the hell are we supposed to take from such a statement? Getting everybody to undetectable status is the universal aim but is pretty pointless if we don’t know how much of the virus has escaped detection because the procedures are lacking. Of course ‘undetectable’ suggests ‘less infectious’ but thirty years into the disease and its treatment and we still don’t know whether that’s entirely true. Until other bodily fluids are routinely tested we’re no closer to an answer and even then, the virus may be hiding in bone marrow, organs and brain tissue. Testing every susceptible piece of the body may never be possible but telling us we’re undetectable but maybe still dangerous, tells us almost nothing; we deserve better.

Another pretty meaningless statement is:

“Research shows that a lower amount of virus in the blood is usually associated with a lower risk of transmitting HIV to others, and a higher viral load is associated with a higher risk.”

Duh! And by the way, what research? We probably all accept the truth of this statement but what research proves that? Far too often the words ‘Research shows…’ are thrown at us in the expectation that we’ll accept that as gospel. Very often research is so small-scale and out of date that it is barely relevant. It is wrong to assume that the reader can’t cope with references to the exact piece of research and it should be expected that research is looked at with a critical eye but very often, ‘research shows…’ will back up a multitude of assumptions.

CATIE quotes HPTN 052 research to back up theories that a lower viral load reduces risk but that research was conducted amongst tiny groups of sero-discordant heterosexual partners in Africa and Thailand. The research is ongoing but trials to measure the same risk reduction when it comes to homosexual, anal sex…well you can whistle for that one! A lot of people hang a lot of credence on HPTN 052 but for HIV+ gay people, it suggests absolutely nothing and proves even less. To be fair, the CATIE article does point this out and even questions the relevance of the research but still draws conclusions that say we can reasonably assume that the same applies to anal sex. Uhm sorry, no it doesn’t!

When a paragraph begins with:

“Successful antiretroviral treatment can lower the viral load in the blood and other bodily fluids to undetectable levels and this can reduce the risk of sexual HIV transmission...Antiretroviral treatment may be much less effective than 96% when these conditions are not met.”

You know that it means very little. We want to know that in the majority of cases, ‘it will’!

More woolly information follows:

“A higher level of HIV in the semen, vaginal fluid, and rectal fluid may increase the risk of transmission when the blood viral load is undetectable. However, it is unclear how often this happens and how significant it is in terms of HIV transmission. Research shows it may be more common if a person has an STI, but can also happen in the absence of STIs.”

There they are again: ‘may’ and ‘can’, plus a ‘research shows’ and an ‘unclear’. How exactly is this useful information? The fact is that the research in all areas of HIV is still shockingly lacking and in the meantime we have to put up with guesswork. That's not good enough in 2013. If there’s no more money for  extensive and indisputable research; or no plans are on the table; or government and scientific bodies are standing in the way; or moral objections are blocking funds it’s the responsibility of HIV sites and organisations to say so and tell their readers the truth. “We just don’t know and this is why we don’t know,” is far more acceptable than ‘cans and maybes’. At least then we know where we stand.

Doesn’t this next sentence just sum it up?

“Although there have been no studies among gay men and other MSM, there has been one report of HIV transmission occurring between two men when the HIV-positive partner had an undetectable viral load.”

Pitiful, really! Are we going to have to take to the streets again to demand efficient and relevant research which will end up saving the state millions in health care and why aren’t our large HIV organisations leading the charge?

The second article comes from aidsmap.com, which is generally regarded (just like CATIE) as a reliable and up-to-date source of information. The introduction is as follows:

“Aidsmap.com reports about 10% of gay men taking antiretroviral treatment have low levels of HIV detectable in their semen, according to new research. Whether or not this level of HIV in semen is associated with transmission is unknown.”

Now I thought this was interesting and went in search of this new research. It stemmed from a University of California study into the effect of the herpes virus on HIV transmission (read more here.) It involved 46 people, split between so-called HIV transmitters and non-transmitters and could hardly be called ‘large scale’. The Aidsmap article refers to 114 men in the study but even that’s hardly a significant research group. The point is that Aidsmap presents this as fact, based on ‘a US study’ when in fact it’s a little more complex than that and to state that 10% of men on HART have low levels of HIV in their semen seems pretty conclusive, yet it is based on a small study concentrating on the Herpes virus. Again, the statement may be true; it may be relevant and important but we need more evidence to back up global statements like that. (Editorial comment. PositiveLite.com says: even more important is whether such low levels of virus have any significance, i.e the ability to result in transmission. Is in fact the semen issue a complete red herring? We suspect yes, given the transmission history -  or lack of it -  in people with undetectable viral load in their blood.)

PositiveLite.com has quite rightly questioned the accuracy of aidsmap's references to the HPTN052 research, which is trundled out yet again yet proves practically nothing for gay men.  (Editorial comment; PositiveLite.com has since received acknowledgement from aidsmap that the aidsmap information was incorrect and that a retraction (apology?)  will be issued shortly. The moral is, as Dave says, question EVERYTHING you read.)

The article then goes on to say:

“But there have been rare case reports of HIV transmissions in the presence of an undetectable viral load”.

What rare case reports? How many? Why isn’t this being investigated right now, on a large scale, to actually establish some facts? It’s almost as if HIV organisations and sites have become so accustomed to writing generalised pieces that repeat the same old suspicions and assumptions, that it has become a new truth of its own. Why aren’t they screaming out for new research and not settling for worn out cliché responses?

It goes on:

“Untreated bacterial sexually transmitted infections (STIs) such as chlamydia and gonorrhoea may cause viral load to increase in genital fluids, even if a person is taking effective antiretroviral treatment.”

‘May’! Why don’t we know for sure?

Finally, statistics are rolled out:

“They also found that 36% of study participants with a detectable viral load were shedding HIV in semen compared to 6% of participants with an undetectable viral load…A urethral bacterial STI was diagnosed in 4% of men, but these untreated infections were not associated with the presence of HIV in semen.”

Okay, let’s assume that the study involved 114 men and not 46. 36% of 114 is 41. Is it really valid to come to wide-reaching conclusions based on the results of 41 people? The urethral bacteria numbers are even less relevant: 5 people out of 114!

The point is that readers take headlines and believe them to be true, when in fact they’re often based on such small-scale studies that they barely merit a mention. Of course, all these studies may be revealing vital information and should be reported but if one (small) study suggests a trend then it should be replicated on a wide scale across the HIV community in order to establish whether it is more than just a medical soundbite. It’s the responsibility of authors and their organisations to look at these things more critically and if necessary make readers aware of the scale and validity of studies, statistics and suppositions.

The reader also needs to question anything that’s not clear, or seems to be stated as fact when it’s not proven. The problem is that life’s just too short to take the time to do that. So the promulgation of half-truths and loaded headlines becomes the easy way out, eventually leading to mistrust and suspicion.

This article of mine may seem like an attack on two highly regarded HIV information sources; it’s not meant to be. I have used them as examples of what we see every day in articles and discussions throughout the HIV community. We really do deserve better than to be fed meaningless conclusions based on ‘maybes’ and ‘possibilities’ but it’s not the fault of the authors. News has to be reported, no matter how tenuous the facts.

Unfortunately, it looks like the HIV community has to start demanding again. Demanding proper, well, funded and large scale research at home and abroad. The World Health Organisation has a responsibility (and the finances), as does the pharmaceutical industry and every other research or research-funding facility across the globe, including the major philanthropists like Bill Gates etc.

I’m fed up with endless arguments as to whether an undetectable status is safe or not, or whether TASP, PrEP, PEP and various other acronyms are the way forward, or whether the viral load in your blood reflects the true levels in your body. Just how safe is condomless sex between sero-positive people on HART? The questions are endless but I would like answers and soon. Some people and organisations are dragging their feet in providing them. It’s a question of having the political will to do the necessary research and damn well prove things once and for all and if the ‘climate’ makes it difficult to instigate the discussion and find the evidence, then we’ll just have to scream and shout until that changes. If it doesn’t happen then confusion drives apathy and stigma grows.

When you next read an article about the latest theory concerning HIV treatment and transmission; count up the number of ‘statistics, if’s, may’s, possibly’s and researches show’ and ask yourself if you are being presented with new facts and are you learning anything new. If the answer is negative then you may well be being short-changed!

I’m fully aware that some people will be irritated by this article but then I hope they’ll respond and widen the discussion. If I’m talking out of my backside, I hope you will say so  - but you’re going to have to prove it! 

March 15, 2013 - 11:30 pm

Met a guy last night online who was visiting LA for the weekend. We meet up this evening and found we had more than just a simple mutual attraction. He's newly POZ (just six months) so when he got an eyefull of the tattoo he was a bit confused but being in the medical field he quickly connected the dots. His reaction, like many, was supportive yet I got the distinct feeling it wasn't for him. Coming from a more traditional background I think being openly gay and now POZ was more than enough for him to deal with though he did have a nice tribal tattoo.  I wonder if the tattoo would have been an issue for him if we wanted something more serious or maybe he would want one as well ... there's a thought.  

March 17, 2013 - 12:30 am 

We decided to meet up late this evening but because I presently have roommates and like my privacy we chose a more ‘interesting’ venue to hang out at, the local gay bathhouse.  To be honest I have avoided the bathhouses for many years as they no longer hold much appeal. But lacking a place, seeing how he had never been to one before and me desiring to gauge the reaction of people to the tattoo in a sexually charged environment, the bathhouse on a late Saturday evening was the perfect place. 

We did the grand tour of the smallest bathhouse in LA and while he was filling his eyes with the sights - bathhouses by nature defy description so I will not attempt - I was focused on the patrons and their reactions … which was nothing.  That said, we were never approached, nor did we approach anyone to get any sort of reaction.  After a thorough once over of the place we retired to our room and later headed out to West Hollywood. 

March 17, 2013, 2:30 am 

We arrived at one of my old haunts, the now remodelled Mickey’s bar for after hours but instead of dancing we found ourselves on the patio talking.  He attended small high school where he was openly gay, a handsome guy who was into weightlifting at the time and had the respect of his fellow classmates.  Now in his early 30’s he was having to quickly come to terms with being HIV+, something he was having issues accepting and this caused him difficulties disclosing.

Knowing he came from a small southern community I asked if he had told anyone of his family he was positive, something I have yet to do.  Upon his diagnose he called his siblings and told them, “I am HIV+, I need you to go on the web tonight and learn about it because when I call you tomorrow I am going to need your support!” and hung up.  He called back the next evening and when they answered the verdict was unanimous “you are not going to die!”  I have to be honest, this was one of the most simple yet powerful disclosure stories I have ever heard.  

March 17, 2013 - 4:30 am 

We spoke some more and being the night was still felt young to us we decided to retire to LA's largest bathhouse to round out the evening.  If I was going to get a reaction to the tattoo I imagined it would be at this location. Though it was late, there were still lots of people awake and looking to connect. We got a room on the ground floor and made a quick tour of this location; it had changed a bit since my last visit years earlier but the general layout remained the same, with a basement, ground floor and upstairs. 

My guest had a mind to get a third to join us, so we set out on a search. There was no shortage of guys and though we made several attempts, whether being a couple was too intimidating or the tattoo worried the players or the general luck of the evening, we were unsuccessful. Neither approached nor shunned, without actually interviewing someone I couldn't say for certain what was the root issue, if any. So much for testing the tattoo at the bathhouses. 

March 24, 2013 - 10:00 pm 

Yet another in my series of my trips to the Korean spa with the tattoo, one guy struck up a conversation about it saying it looked like the Olympic symbol (it does have three semi concentric rings), I corrected him saying it was actually a biohazard symbol and left it at that.  I was not particularly interested in informing him of my status as this was still the Korean spa and I didn't feel entirely comfortable just announcing my status randomly, sort of defeats the idea of limiting disclosure.  However if he pressed me I would have willingly explained why I was wearing the tattoo as it’s purpose is to promote discussion and it definitely empowers me to disclose. 

March 26, 11:45 pm 

Sitting in the spa at the gym before closing, just myself and another guy (seen him before never talked to him), when out of the blue he commented on the tattoo saying it looked like a gay symbol. (In fact the biohazard tatt is rainbow coloured so it serves to ID me as gay to the observant).  In context this was the day of the US Supreme Court hearing the arguments regarding the Defense Of Marriage Act (DOMA) and the following day they were scheduled to hear Proposition 8 arguments and he was curious how I felt about it as well as the possible outcome.  This was fascinating, as the tattoo appears to get people talking about things that are close to my heart other than just my status. This was a great and most unanticipated result. 

March 30, 2013 9:00 pm 

Arrived late to the Korean spa. I had problems applying the tattoo that evening; the skin seems oddly irritated but I ignored this and off to the spa I went. Only ten minutes into my visit I notice the tattoo, a thin sheet of acetate glued to my skin, was bubbling up. Argh! I pressed hard to get it to adhere and thought it would just stick ... it didn't.  The temporary tattoo that I usually wore for three to five days without any issues was coming unglued.  By the time I was done with my 70 minute session it had peeled up to the point that once I returned to my locker to change I needed to remove it.  It appears my skin has built up an allergic reaction causing the temporary tattoo to not only bubble up but actually cause physical pain to the application site.

So no more temporary tats, the universe has spoken! 

April 1, 2103 10:45 pm 

In the shower at the gym the following evening, a sexy young black guy is one shower over and is clearly looking for some action. Never been one for public play but without the tattoo I felt oddly more naked than I already was ... interesting that the tattoo appears to work for me both as a shield as well as a warning. 

April 6, 11:30 am 

Finally I made contact with Jill Jordan, a highly respected and innovative tattoo artist! Set an appointment with her for April 14th at 1:00 pm. My gym buddy Alonso is so excited he also wants to meet Jill (he has a tattoo of his own in mind). 

April 7, 2013 9:00 pm 

I meet up with my first former bf David while he was visiting LA and being that he was one of the inner circle of people who knew I was poz I wasted no time telling him about my desire to get the biohazard tattoo. Why open with the tattoo? David and I have also had a very deep connection on a spiritual level and I wanted to hear him ask "what is your intention?" 

I gave him my canned answer - it will make it easier to disclose, show solidarity to the HIV+ community, etc., yet I was merely buying time to really look deeper and see if I could find an even more tangible answer. This was always the way with us because of our connection and frankly it's quite refreshing to speak about life in terms of spirit and action.  Oddly I rarely avail myself of such opportunities anymore ... makes me wonder why. 

We had both been through some serious life events, broken relationships, health and financial issues, yet we seemed to be better off for it all.  By the end of the evening I was feeling very comfortable with David again and was ready to give him a better answer with regards to my intent of getting the tattoo. 

First, I wasn't branding my soul, only the body. It reminds me to be mindful of the infection but not overwhelmed by it. A few years ago I might have found such a reminder very disturbing, a constant reflection of a mistake I made and was unable to undo. But now much, like knowing I will die, I am coming to terms with it. The tattoo reminds me my life and time on this earth is precious as well as short and to embrace life at every opportunity. 

Second, the tattoo is a method of communication of not just my HIV status or that I am gay (the rainbow flag has many people identifying as a gay symbol) but purely as an art form with a language all its own.  I trust many will appreciate it on many levels but haters will hate and how I deal with such situations will be a measure of my own growth.  Most reactions have been good and I predict that though this seems like a bold act now it will be passé in 10 years but no less important to me! 

Lastly, it memorializes the freedom of my mind if not body from HIV (my spirit has always been free and I am beginning to appreciate that more and more). David applauded my intention and asked me to meditate further on this act. II told him I would and let him know what conclusions I reached. 

April 10, 10:00 pm 

Over the following days I considered what David and I talked about and we shared more messages over FaceBook when it dawned upon us - damn this tattoo really does get people talking. That’s when it hit me this was an immerging aspect, not just to communicate to other people but to get people talking - about HIV, about gay issues, breaking down the barriers we put up in our daily lives.  I am not so naïve to think this tattoo will change the world but getting people talking is a great start! 

This article first appeared on the CATIE website here.  

Une version française est disponible ici.  

The importance of HIV testing, knowledge of HIV status and early diagnosis of HIV infection cannot be overstated, particularly given recent advancements in our understanding of HIV treatment and prevention. 

People who are aware of their HIV-positive status can access care and support services and initiate treatment when they are ready. Advances in treatment mean that people with HIV can live almost as long and as healthy as people who are uninfected. To get the most out of treatment, research suggests it may need to be started soon after becoming infected with the virus. Currently, however, many people in Canada are not learning about their HIV status until late in their disease, when they start to develop symptoms or opportunistic infections. At this point, antiretroviral treatment can help improve their health but not as effectively as when treatment is started earlier. 

Knowledge of HIV status is also important for the prevention of HIV transmission. Generally, once people become aware of their HIV infection, they take measures to reduce their risk of HIV transmission. Also, once diagnosed, treatment can be initiated and this can further help reduce the risk of HIV transmission. Research suggests that the majority of HIV transmissions may originate from people who are unaware of their HIV status. 

For those who test negative, testing represents an important opportunity to provide HIV prevention information and counselling. 

According to 2011 estimates from the Public Health Agency of Canada (PHAC), approximately 25% of people living with HIV in Canada were unaware of their HIV status. Therefore, undiagnosed HIV infection represents a major public health challenge and is undermining HIV treatment and prevention in Canada. 

Barriers to testing 

There are several barriers to increasing the uptake of HIV testing and reducing the proportion of people who are undiagnosed in Canada. According to a synthesis of the evidence conducted by the European Center for Disease Prevention and Control and published in 2010, these barriers include: 

• inability to accurately assess levels of risk for exposure to HIV by some clients and providers
• lack of comfort discussing HIV testing and lack of knowledge about HIV among clients and providers
• provider time constraints for risk assessments and pre- and post-test counselling
• cumbersome consent procedures
• fear of stigma and discrimination associated with risk behaviors and/or testing HIV positive 

PHAC guidelines and recommendations 

PHAC recently released an HIV Screening and Testing Guide that “seeks to reduce the number of undiagnosed HIV infections in Canada by offering a framework for care providers to explore options that will enhance their ability to provide HIV testing, as well as to better tailor their testing approaches to meet the specific needs of their practice and clients.” 

These guidelines include the following recommendations to address the barriers listed above and to improve HIV testing in Canada. 

The offer of an HIV test should be made part of periodic routine medical care.The guide acknowledges that targeted testing among populations at highest risk of HIV infection needs to continue but should be complemented with a less targeted testing approach among populations that may be perceived as being lower risk. Research shows that many people at risk for HIV infection (including those who are later diagnosed with HIV) are not requesting, or being offered, an HIV test despite multiple interactions with the health system, likely because of perceived low risk of HIV infection on the part of the client and provider. These interactions represent “missed opportunities” for HIV testing and potential diagnosis of HIV infection. 

Therefore, a major recommendation in the guide is that providers take a more active approach and routinely offer HIV testing to clients—whether or not they have asked for a test. Routinely offering HIV testing to patients will help overcome some of the barriers to testing. Also, it may help normalize HIV testing and further reduce stigma and discrimination associated with HIV. 

To reduce the fear often associated with an HIV diagnosis, which can be a barrier to testing, the guide recommends that care providers emphasize the benefits of treatment and that HIV is now considered a chronic manageable condition. 

Simplify risk assessments. 

The guide acknowledges pre-test risk assessments as a potential barrier to HIV testing. Therefore, it states that instead of providing an in-depth comprehensive HIV behavioural risk assessment prior to offering an HIV test, a more brief assessment is sufficient. This assessment should ensure that clients understand the following: 

• how HIV is transmitted
• the advantages and disadvantages of HIV testing
• how to interpret the results 

After the brief assessment, a client should simply be asked if they want an HIV test. This approach allows the client to assess their own risk without feeling compelled to provide sensitive personal information. This helps to overcome any discomfort the tester and/or client may feel in discussing these issues, which can sometimes be a barrier to testing.  

HIV testing must remain voluntary and based on informed consent. 

The guide states that verbal consent prior to HIV testing is sufficient and written consent prior is not necessary. 

Use a flexible approach to pre- and post-test counselling. 

The guide encourages care providers to use a flexible approach and tailor the extent of pre- and post-test counselling to each client’s unique needs and situation. While providing extended counselling is preferred, the guide acknowledges that this may be a barrier for both the provider and client, particularly due to time and resource constraints. More specifically, the guide states that shorter counselling may be more appropriate for certain testers, such as pregnant women in labour, well-informed patients and repeat testers. The provision of print, video, mobile and web-based resources can help streamline the pre-test process and inform decisions with regards to HIV testing.

 Offer couples testing. 

The guide stresses the importance of testing together for those in an ongoing sexual relationship with a regular partner as it allows: 

• a common understanding of the risks associated with HIV transmission
• a shared understanding of each other’s HIV status
• an opportunity to make decisions about prevention, treatment and care together 

Research studies suggest that couples who test and learn their status together are more likely to adopt preventive measures than those who test alone. 

Integrate HIV testing services. 

The guide encourages the integration of HIV testing into other services, particularly those that test for infections that can be transmitted the same way as HIV and/or negatively impact the health of people living with HIV. 

These services include the following: 

• clinical services for tuberculosis (TB), sexually transmitted infections (STIs) and hepatitis C
• antenatal care services
• sexual Health and family planning services
• drug and alcohol treatment services
• newcomer and travel health clinics
• mental illness treatment and psychiatric services
• cancer or oncology clinics 

Integrating HIV testing into these other services provides additional opportunities to test for HIV and identify undiagnosed individuals. 

While positive results should always be provided in person (preferably by the initial care provider), alternate approaches can be used to provide negative results. 

Ideally, negative test results should be provided in person, however, the guide acknowledges that this can be challenging to do for all individuals. Therefore, providers can use a previously agreed upon alternative for those who are unlikely to return for their test results. These alternative approaches may include a secure telephone call, letter or email. The guide emphasizes that effort should be made to ensure that the information is provided confidentially. 

It is important that clients are not informed that only HIV-positive results will be provided in person. This may create anxiety when a person is asked to return to get their results in person. 

Discuss the window period with those who test HIV negative. 

If someone is “in the window period,” there is a chance that even though they may have been infected with HIV, the test won’t be able to detect the infection and will give a negative result. The window period differs for each type of HIV test and also depends on each individual. To ensure that a person was not in the window period at the time the test was performed, the guide recommends that follow-up testing be performed at three weeks and three months following the most recent possible exposure. However, the guide states that additional HIV testing during the window period, particularly following a “high-risk” exposure, may help identify infection earlier. 

Discuss frequency of retesting with those who test HIV negative. 

The guide recommends that individuals involved in “high-risk practices” be screened for HIV at least once a year. Since many variables determine an individual’s potential risk of HIV infection, the guide does not recommend an exact frequency of HIV testing for different levels of risk. However, when considering the need for retesting, the guide recommends that care providers consider factors such as populations at increased risk for HIV exposure, characteristics of partners and local epidemiology. 

Provide information and referrals—regardless of test results—and link newly diagnosed individuals to care. 

HIV testing is an important opportunity to educate individuals at risk of acquiring HIV and those who are newly diagnosed and link them to additional services. For example, all people tested for HIV—regardless of their results—should be provided with information and linked to services to help them reduce their risk of acquiring or transmitting HIV. Therefore, in preparation for HIV testing, the guide suggests that providers contact care and support organizations to obtain referral resources to provide to clients. 

Research shows that people living with HIV who are linked to and engaged in care have better health outcomes than those who are not. Therefore, newly diagnosed individuals should be referred to an infectious disease specialist who treats HIV. Also, effort should be made to complete baseline testing for CD4 count, viral load, drug resistance and co-infections (hepatitis B and C, STIs, TB) as soon after diagnosis as possible. 

For those who test HIV positive, develop a partner notification plan and discuss public health importance of disclosure. 

Previous and current partners of newly diagnosed individuals represent a population at high risk of HIV infection. Therefore, notifying previous/current partners and encouraging them to get tested may help identify undiagnosed HIV infections. The guide encourages care providers to develop partner notification plans with newly diagnosed individuals. Also, care providers should inform clients that positive test results will be shared with Public Health, which can help with partner notification while maintaining the client’s anonymity and privacy. 

Voluntary disclosure of HIV status to partners has several potential benefits. For example, it may motivate partners to seek testing and/or adopt measures to prevent HIV transmission. Also, it provides an opportunity for the HIV-positive person to receive social support, develop risk-reduction strategies with partners and prevent co-infections. Therefore, the guide states that care providers should emphasize the importance of voluntary disclosure of HIV status to those who are newly diagnosed. 

Conclusion 

PHAC’s new HIV Screening and Testing Guide contains a series of recommendations to increase the uptake of HIV testing, reduce the proportion of people who are unaware of their HIV infection and diagnose people as early as possible after HIV infection. These goals are critical for improving the health of people living with HIV and for preventing HIV transmissions in Canada. One way the guide seeks to meet these goals is by normalizing HIV testing and making the offer of such testing a routine part of medical care. More nuanced and detailed information can be found in the full guide. 

It is important to note that PHAC’s guide is only meant to complement existing efforts and “does not supersede any provincial/territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern and inform the practice of care providers in their respective jurisdictions. Care providers should comply with local Public Health regulations with conducting HIV testing.” 

- James Wilton 

Resources  

HIV Screening and Testing Guide – Public Health Agency of Canada 

WHO guidelines encourage couples HIV testing and counselling and use of antiretroviral treatment for prevention – Prevention in Focus  

Recently infected individuals: a priority for HIV prevention – Prevention in Focus  

Detecting HIV earlier: Advances in HIV testing – Prevention in Focus  

A rapid approach to community-based HIV testing – Prevention in Focus  

How do you know if you have HIV? – Managing your health  

References  

Johnson LF et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Medicine, 10:4. E1001418. 

May M et al. Life expectancy of HIV-1-positive individuals approaches normal, conditional on response to antiretroviral therapy: UK collaborative HIV cohort study. Eleventh International Congress on Drug Therapy in HIV Infection, Glasgow, abstract O133, 2012. 

Van Sighem AI, Gras LAJ, Reiss P, Brinkman K, De Wolf F. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. AIDS. 2010 Jun 19;24(10):1527–35. 

Nakagawa F, Lodwick RK, Smith CJ, Smith R, Cambiano V, Lundgren JD, et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS. 2012 Jan;26(3):335–43. 

Nakagawa F, May M, Phillips A. Life expectancy living with HIV: recent estimates and future implications. Curr. Opin. Infect. Dis. 2013 Feb;26(1):17–25. 

Siegfried N, Uthman OA, Rutherford GW. Optimal time for initiation of antiretroviral therapy in asymptomatic, HIV-infected, treatment-naive adults. Cochrane Database of Systematic Reviews. 2010 Mar 17;(3):CD008272. 

Althoff KN, Gange SJ, Klein MB et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clinical Infectious Diseases. 2010 Jun;50(11):1512–20. 

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This article by Gus Cairns first appeared on aidsmap.com here.  

Data from two national sex surveys in the United States show that gay and bisexual men (men who have sex with men, MSM) reported significantly fewer sexual partners in the previous year in a survey conducted between 2006 and 2010 than they did in one conducted in 2002. This decline was consistent across most ethnicities and age groups, but was particularly marked, and statistically significant, in younger men aged under 24.

In contrast, the proportion who reported having condomless anal sex at least once in the previous year did not change between surveys. In the minority of men who also had sex with women, condom use fell markedly, but on the other hand the proportion of MSM who also had sex with women fell too.  

The proportion of men who tested for HIV or for sexually transmitted infections (STIs) in the last year did not change, although the proportion who had never tested for HIV fell.

The survey

The data come from the last two National Surveys of Family Growth (NSFGs). The NSFG is a survey of 15 to 44-year-olds; participants are contacted at random by phone but due to lower contact/response rates, people under 24, black people and Hispanic people are ‘oversampled’, i.e. a higher proportion are initially contacted than are in the general population.

NSFGs used to be conducted every three to seven years, but in 2006 a decision was taken to conduct interviews (by voice-assisted automated computer interview) continuously. This study therefore compared figures from interviews conducted in 2002 with ones conducted in 2006 to 2010.

NSFG interviewed 4928 and 10403 men in 2002 and 2006 to 2010, respectively. Of these, 197 and 272 reported having a male sexual partner in the last year – 2.7 and 2.1% respectively (this difference was not statistically significant, p = 0.1).

The results

The mean number of male sexual partners MSM reported in the previous year fell significantly from 2.9 to 2.3 between the two surveys (p = 0.035) and was more marked in men under 24 years old (mean 2.9 to 2.1 partners, p = 0.027). The number of partners also fell in men aged 35 to 44 from 3.0 to 2.2, though this was not quite statistically significant (p = 0.07).

The fall in the number of partners was statistically significant in men with incomes under 150% of the US federal poverty level (3.0 to 2.1) and in men living in suburban metropolitan areas (3.2 to 2.1) but not in city-centre areas (2.6 in both surveys). There were declines in partner numbers in white (3.0 to 2.5) and black (2.4 to 1.9) men, though these did not reach statistical significance. In general though, there was a consistent picture of fewer partners among most groups.

There were no changes in condom use for anal sex. In 2002, 57% of men had not used a condom the last time they had sex and in 2006 to 2010 the proportion was 58%. In the minority of men who also had sex with women, the proportion who had not used a condom the last time they had vaginal sex was 46% in 2002 but had become 67% by 2006 tp 2010, and this difference was statistically significant (p = 0.04). However, the proportion of MSM who had had female partners also decreased from 38 to 25% (p = 0.03).

One other notable difference was that fewer men reported transactional sex (sex for money or drugs) in the last year (down from 15 to 3%) and fewer men said they had injected drugs or had had sex with someone who had injected drugs (from 12 to 5%).

HIV and STI testing in the last year did not increase. In 2002 and 2006 to 2010, 41% of men said they had had an HIV test in the last year and in the case of STI check-ups 38% reported having one in 2002 and 39% in 2006 to 2010. The proportion of men who had never had an HIV test, however, fell from 25 to 15%.

Conclusions and comments

The researchers comment on the fact that HIV prevalence and the incidence of STIs increased in gay men during a period when numbers of partners and some other sexual risk behaviours were falling. They note that there have been previous studies in Seattle and Peru where STI incidence and/or HIV diagnoses have remained high even though sexual risk indicators in gay men have fallen. Studies of young black gay men in the US, including one recently presented at the 20th Conference on Retroviruses and Opportunistic Infections (CROI), have consistently shown that they tend to have fewer partners despite considerably higher HIV incidence.

The researchers speculate that this may be due to ‘network factors’: factors about partners that are not captured by the individual risk behaviour focus of most studies. For instance, some studies have found that black gay men tend to restrict sex to partners of their own ethnicity and are also more likely to have sex with men a number of years older or younger than themselves. Both of these would tend to concentrate HIV infection within the black gay community.  

Whether these are the main drivers of US black men’s greater vulnerability to HIV infection, another interesting aspect of this study is that gay men appear to have taken steps that could reduce their HIV risk by using a method that has received little emphasis in HIV prevention programmes for gay men – reducing their number of partners – while not increasing condom use, which has received the most emphasis.

Leichliter JS et al. Temporal trends in sexual behaviour among men who have sex with men in the United States, 2002 to 2006-10. J Acquir Immun Defic Syndr, early online publication, DOI: 10.1097/QAI.0b013e31828e0cfc, 2013.