Clinicians, researchers and representatives from Montreal’s gay community are joining forces to launch a major study, the IPERGAY trial (CTN 268), to evaluate the effectiveness of the drug Truvada in preventing HIV acquisition among individuals who are uninfected but at high risk. If it proves effective, this approach could contribute to eliminating the transmission of the virus that causes AIDS.

In a context in which gay and bisexual men are disproportionately affected by the epidemic (in Montreal, HIV prevalence within this population is estimated to be 13%), community members are mobilizing to assess how new prevention strategies can be added to existing approaches such as condom use.

The IPERGAY study involves comparing the drug Truvada to a placebo (a pill with no active ingredients). Participants will also receive prevention counselling, condoms, and other support, and their well-being will be closely monitored throughout the study. In addition, all participants will be tested for HIV at regular intervals and comprehensive medical care will be provided if an infection is detected.  Part of an international study, the trial aims to include approximately 500 men who have sex with men in Quebec, who will be enrolled for 4 years.  The Montreal study site will be based at CHUM-Hotel-Dieu in collaboration with clinics specializing in HIV treatment and community groups who do outreach to men who are potential candidates for the study.

The concept of daily pre-exposure prophylaxis (taking the medication every day on an ongoing basis) has shown some efficacy in previous studies. However, the success of this approach is dependent on the drug being taken very consistently each day, which can be difficult to maintain over a long period especially among individuals who are not sick. Daily pre-exposure prophylaxis is already starting to be used, but only on a very limited basis. For this reason, we want to rigorously evaluate a different concept, “on-demand” prophylaxis (taken when needed based on the frequency of sexual relations) that has not yet been scientifically validated. Our goal is to learn whether this approach is effective in preventing HIV infection, how easy it is to maintain over the long-term, and how it can be integrated into overall HIV prevention efforts in Montreal.

In the fight against HIV/AIDS, we are living in a period of renewal that has given new hope that an AIDS-free generation may one day be possible. Since the beginning of the epidemic, concerted efforts within the communities hardest hit by the virus as well as by clinicians and researchers have succeeded in transforming a fatal disease into a manageable chronic illness and have inspired belief in the possibility of its eventual eradication.  We are now, once again, gathering our forces to advance the fight one step further.

For more information about the IPERGAY study, please contact:  Ms. Pascale Arlotto, 514-890-8000 ext 15195; This email address is being protected from spambots. You need JavaScript enabled to view it.  

Cécile Tremblay, MD, FRCPC, Principal Investigator, IPERGAY Study – Quebec; Centre Hospitalier de l'Université de Montréal (CHUM); Institut National de Santé Publique du Québec

Mark Wainberg, PhD, Professor, Lady Davis Institute, McGill University

Robert Rousseau, Executive Director, REZO – Santé et mieux-être des hommes gais et bisexuels

Ken Monteith, Executive Director, COCQ-SIDA

Joanne Otis, Canada Research Chair in Health Education (CReCES), UQAM

Thomas Haig PhD, Coordinator, SPOT Project, CReCES, UQAM

Pascale Arlotto, Research Coordinator, CHUM

Gabriel Girard, PhD, Concordia University

Benoit Trottier, MD, Clinique L’Actuel, CHUM

Jean-Guy Baril, MD, Clinique Quartier latin, CHUM

David Thompson, President, Board of Directors, RÉZO

CTN researcher, Dr. Cécile Tremblay is an infectious disease specialist based at the University of Montreal's Faculty of Medicine. Dr. Tremblay is also the Director of Quebec's public health laboratory and she is the Canadian principal investigator for the CTN 268 ANRS IPERGAY trial

Recent advances in a number of research fields, particularly the antiretrovirals (ARVs) have largely transformed HIV/AIDS from a painful death sentence to a manageable illness. And additional advances in peripheral fields like gene therapy, vaccines, cellular manipulation, etc., actually have immunologists and researches using the word “cure” without fear of being tagged as irresponsible pipe-dreamers. However, so far the hypothetical end-product of most of these research paths have been qualified as “functional cures”.

A functional cure is generally defined as one in which the virus has been beaten into harmless remission and remains there without the need for adhering to an expensive drug regimen.

While remission and freedom from reliance on the cocktail is nothing to turn one’s nose up at, even the most effective treatments leave concentrations of the HIV virus lingering in the body. These viral “reservoirs” (or “latent reservoirs”) are problematic chiefly because in most HIV-positive people, when drug therapy stops, those reservoirs soon flood the body and the immune system is once again attacked. To affect an actual cure, the viral reservoirs in the brain/central nervous system, gut and other common retreats for dormant HIV must be flushed out where it can be killed by ARVs. If not, relapse is a near certainty. Researchers are working to find flushing agents on several fronts. Here are some of the most promising:

HAART. Dr. David Ho is probably one of the two biggest names in HIV research; the other being Dr. Robert Gallo. 1996 Time Man of the Year Ho has dedicated a considerable portion of his career to highly active retroviral therapy (HAART). HAART treatments block the action of reverse transcriptase and protease - two enzymes necessary to HIV’s replication and cell infiltration. Ho believes that if a patient strictly abides by their HAART drug regime even the viruses hiding in the latent reservoirs could be disabled and eliminated in roughly six years.

Drawbacks. As is the case with any powerful drugs, the HAART cocktail’s side effects can be rough and even dangerous. Plus, a sizable chunk of those committed to HIV research insist that no drug therapy can eradicate the virus entirely.

HDAC Inhibitors or HDIs. Histone deacetylase inhibitors (HDACs or HDIs) have long been used as mood-stabilizers and anti-epileptics and more recently have proved promising for battling cancer. Within the past few years, however, they’ve come to the attention of immuno-virologist specialists for their apparent efficiency at highlighting and purging dormant HIV from the cells concealing them. The two being most actively investigated are vorinostat and valproic acid.

Drawbacks. Once again, while the results emerging from very small-scale clinical trials has been promising, use of HDIs in the fight against HIV is new and they may prove prohibitively toxic. Aforementioned HIV pioneer Dr. Robert Gallo (among others) further warns that there is no 100% guarantee that all of the flushed virus will be dead or killed. If the HDIs don’t work as is hoped, they could actually contribute to the establishment of more entrenched latent reservoirs in the brain.

Disulfiram. In another strange case of drugs better known for their use in the treatment of unrelated, psychiatric/neurological disorders (and perhaps cancer), the drug disulfiram is both better known as Antabuse and for its use in the treatment of chronic alcoholism by creating an acute sensitivity to alcohol. In the lab and limited clinical trials, though, disulfiram did exhibit potential as a reservoir-draining latent HIV activator.

Drawbacks. Over the long term, disulfiram trials saw a reservoir-depletion of around 14%; which is statistically insignificant. However, researchers found that it was efficacious in short-term latent viral activation and was well tolerated, meaning it could be incorporated into a broader treatment strategy. The most troubling drawback, of course, is that one couldn’t drink during disulfiram treatment!

Prostratin and DPP. Prostratin and its chemical cousin DPP are poignant arguments for the preservation and study of forests and traditional medicinal practices around the world. They are chemicals initially derived from the bark of the Somoan mamala tree, a resource locals have been using to battle blood disorders for years. Early research into prostratin and DPP’s viability as a latent HIV activator and reservoir-depletion mechanism has been encouraging.

Drawbacks. Synthesizing prostratin and DPP have proved difficult considering the rarity of their source material and relative newness of their appearance. That newness is another drawback as possible side-effects, long-term repercussions and long-term effectiveness are not well known.

As hopeful as the prognosis is for any or all of these treatments, virtually all scientists point out that this sort of research is in its relative infancy. It’s also a branch of HIV-eradication medicine that is something of an all-or-nothing proposition. Even an effectiveness of 95% is five percent too little.

Guest writer Jim Fox is a freelance writer who studied medicine for his undergraduate degree. He frequently writes about topics pertaining to the medical industry, including affordable RX drugs.  When he isn't typing the day away, Jim is either perfecting his wine recipes or lacing up his ice skates and heading for the nearest frozen water.

This article first appeared on aidsmap.com here. Republished with permission.  

A study of a sample of predominantly African-American people with HIV in the US has found that, in those taking antiretroviral therapy (ART), only 51% met the criteria for non-infectiousness set by the Swiss Statement of January 2008.

This study (published in HIV Medicine), though small, underlines other findings that African Americans are missing out on the benefits of ART. The high proportion of people with detectable virus while on ART in this study was apparently driven by poor adherence, but may have been amplified by a high rate of untreated sexually transmitted infections (STIs).

Background

The Swiss Statement said that people who have had an undetectable viral load (below 40 copies/ml) for at least six months, who have no sexually transmitted infections, and who have their adherence regularly monitored by their physician, can be regarded as non-infectious. The statement became regarded as a landmark in the development of giving treatment to suppress viral load as an HIV prevention strategy, as well as for the treatment of individuals.

Researchers from the University of Connecticut, who pioneered the study and development of programmes to change HIV risk behaviour, recruited 228 people living with HIV from local STI clinics through community sampling.

Demographics

Ninety-one per cent of the people in the study were African American, 54% defined as gay men, 24% were heterosexual men and 22% were women. Their average age was 45. This was a socially deprived group: no less than 73% had been in prison at some point in the past year, and 61% earned less than $10,000 a year (£6265).

One criterion was that they had to have drunk alcohol in the past week, as this is part of a research programme looking into the influence of alcohol in risk behaviour, but alcohol intake turned out not to be one of the factors that influenced infectiousness. Twenty-two per cent had a drink more than one day a week and only 11 people four or more days a week; 12% had five or more drinks when they did drink.

Viral load and adherence

Eighty-one per cent (185) of people were taking ART. The only demographic factor associated with being on ART was that people who managed to avoid prison during the year were 2.8 times more likely to be on ART than people who had been incarcerated.

Of people on ART, 25% had a detectable viral load at the beginning of the study and 15% at the end of it a year later, with a third having a detectable viral load at least once. Twenty-four per cent had an STI during the past year. Adding these together meant that only 51% of people on ART fitted the Swiss Statement criteria for non-infectiousness for the year of the study. The only demographic characteristic associated with having an undetectable viral load was being married: more than twice as many people who were married had an undetectable viral load than people who were unmarried.

Adherence was measured by ‘unannounced pill count’, which meant participants were phoned up randomly and asked to count their pills over the phone. It was 86% in those with an undetectable viral load and 79% in people who were detectable; 32% and 37% respectively had adherence of below 85%. This may not sound like a big difference but it was strongly statistically significant; people with adherence below 85% were 18 times more likely to have a detectable viral load at one of the two time-points.

Risk behaviour and viral load beliefs

Evidence that receiving ART was associated with increased sexual risk behaviour was ambiguous. Just under half of the people receiving ART reported sex with partners with a negative or undetectable viral load (in the last four months) and only 26% of those not receiving ART; statistically, people on ART were 2.7 times more likely to have serodiscordant sex than people not on ART. On the other hand, people on ART were no more likely to report unprotected sex with serodiscordant partners (29 vs 26%, odds ratio 1.13). People on ART were twice as likely to report having had an STI (24 vs 12%) although this failed to be statistically significant (p=0.1).

One of the more worrying findings of the survey was that one in four people thought their viral load was other than it was. Although this included people who were not infectious by Swiss Statement criteria when they thought they were, people with a detectable viral load who thought they were undetectable were more common, with a third of people with detectable viral load believing they were undetectable at the start of the study. Thus had gone down to one in five people a year later.

The researchers comment: “The Swiss Statement unambiguously specifies the circumstances under which a person with HIV should be considered non-infectious.

“Unfortunately, these conditions do not reflect the realities of many people living with HIV.”

Reference

Kalichman SC et al. Assumed infectiousness, treatment adherence and sexual behaviours: applying the Swiss Statement on infectiousness to HIV-positive alcohol drinkers. HIV Medicine DOI: 10.1111/j.1468-1293.2102.01062.x. 2012.

This article by Gus Cairns first appeared on aidsmap.com here and is republished with permission. 

A survey of over 2000 gay men attending clinics in the UK has found that 48% disagree that HIV treatment can make someone less infectious or makes it unnecessary to use a condom, the eleventh International Congress on Drug Therapy in HIV Infection in Glasgow heard this week.

Although the ASTRA (Antiretrovirals, Sexual Transmission Risk and Attitudes) survey found that only 15% of men had recently had unprotected sex with someone of negative or unknown HIV status (serodiscordant unprotected anal intercourse or sdUAI), it discovered that that the minority of men who were not taking antiretroviral therapy (ART) were actually rather more, rather than less, likely to have unprotected sex with a partner of negative or unknown HIV status than men taking ART.

However, in gay men who were taking ART, those with a detectable viral load were considerably less likely to have sdUAI than men with an undetectable viral load, suggesting some men are taking their viral load into account when making decisions about unprotected sex.

The survey also found that beliefs about viral load and infectiousness did have an influence on safer-sex decisions, with men who did not believe that viral load reduces infectiousness being less than half as likely to have sdUAI as men who believed that it did.

Study details

For this study, questions answered by 2086 men out of over 3000 answered in the last year were analysed. Their average age was 43, 88% were white and 85% were on ART. Of these 83% had an undetectable viral load, so over 70% of the whole group had an undetectable viral load on treatment. Just over 8% of men knew they had a detectable viral load and the same proportion did not know their viral load.

The men were asked whether they agreed with two statements: “When a viral load is undetectable, condoms are not needed to prevent HIV transmission” and “Undetectable viral load makes someone less infectious to a sexual partner”. Only 4% agreed with the first statement; 48% agreed with the second, leaving another 48% who agreed with neither.

Just under two-thirds of the men (64%) had had any anal intercourse in the last three months, and 37% had had any unprotected sex, but over half of these only had unprotected sex with another positive partner or partners. This means that 15% had sdUAI: of these 40% only took the receptive role when they had unprotected sex, indicating some ‘seropositioning’ behaviour, while 20% only had sdUAI with one regular partner.

Serodiscordant UAI was actually rather more common in men who were not on ART: 20% (3% of the whole group) were not on ART but had sdUAI, while 14% of men on ART (12% of the whole group) had sdUAI. Thus men off ART were 25% more likely to have sdUAI then men on it, and this was statistically significant (p=0.006). However, only 9.4% of men who were on ART but did not have an undetectable viral load had sdUAI, so if men were on ART, they were 40% less likely to have sdUAI than if they were detectable.

One reason men not taking ART might have more unprotected sex is because sdUAI was high in men who had only recently been diagnosed: 23% of men diagnosed within the last three months had sdUAI, but more than three months after diagnosis this had reverted to 14%. Young people (who might be more recently diagnosed and less likely to be on ART) were also more likely to have sdUAI: 24% did so.

Other factors associated with sdUAI were recreational drug use, which more than doubled the likelihood of sdUAI, and alcohol, which increased it by 50%; men with hepatitis C were also 50% more likely to have sdUAI, though this may be effect rather than cause. Ethnicity, employment, education, smoking and CD4 count were not associated with sdUAI and importantly, in this study at least, depression was not associated with it.

The chance of having sdUAI increased with the number of partners men had. While 39% of men had not sex in the last year, one in eight had had more than 20 partners and 4.4% more than 50. Amongst these latter groups, respectively a third and nearly a half had had sdUAI in the last three months.

These findings obviously have, as the researchers comment, implications for prevention strategies in the UK, particularly in terms of the complex question of whether making people aware of the benefits of treatment as prevention may have the effect of increasing risk behaviour.

Reference

Lampe F et al. ART use, viral suppression and sexual behaviour among HIV-diagnosed MSM in the UK: results from the antiretrovirals, sexual transmission risk and attitudes (ASTRA) study. Eleventh International Congress on Drug Therapy in HIV Infection, Glasgow, abstract O323, 2012. View abstract here.

This article by Gus Cairns originally appeared on aidsmap.com here and is republished with permission.

“I’ve been getting very cross with articles – including one I read in HTU – that emphasise how people with HIV are going to die 10 to 15 years younger,” says John, 70. “My recipe for long life is always to think positive and to refuse to be a victim of HIV,” he adds.

John is referring to the oft-cited assertion that people with HIV age 10 to 15 years in advance of other people2 – in other words that a 60 year-old with HIV has a biological age of 75.

Is this inevitable? Or does it involve factors we can control?

Will we age quicker?

People diagnosed in the last few years who start antiretroviral therapy (ART) at a sufficiently high CD4 count, and stay on it, are likely to have a normal lifespan. One recent UK study found that a non-smoking, 30-year-old gay man, whose HIV is diagnosed promptly, could expect to live until he is 78, the same age as the average UK male.3

This doesn’t hold for everyone with HIV, though. Another recent study of life expectancy in people on ART found that, compared to the general UK population, life expectancy at age 20 was 18.3 years less for men and 11.4 years less for women.4 That means that, on average, life expectancy for someone aged 20 would be 59 if a man and 71 if a woman. Why the disagreement between studies?

On the one hand, excluding AIDS-defining illnesses – which now cause only a small minority of deaths in people taking ART5 – people with HIV also have higher rates of many other illnesses. They have about twice as much cardiovascular disease and 60% more heart attacks than the general population,6 are much more likely to get bacterial pneumonia7 and are at raised risks of many cancers.

On the other hand, this life expectancy deficit is overwhelmingly concentrated in people who are diagnosed late, and most of the deaths that bring the average life expectancy down occur in the first year after diagnosis.8 Also, life expectancy is an estimate of how long we might expect to live given current conditions and no further medical advances.

Anyway, who says you are average? If you’re reading HTU, you’re probably not. Half of HTU’s readers are over 50 – over twice the proportion in the general HIV-positive population. If you’ve already got that far, your life expectancy will now extend beyond 59 – and a lot of you will have reached that age already.

Medical issues in older people with HIV

Dr Mike Youle is an HIV doctor with a particular interest in the health of older people. 

“Some changes are inevitable natural processes,” he says. “Take high blood pressure. It’s not good for you, but given that it rises in virtually everyone as they age, is it an ‘illness’ or just a consequence of ageing that develops at different rates in different people?”

He thinks a lot of the observed deficit in life expectancy and overall health is due to the legacy of untreated AIDS in the pre-ART era.

“A person who’s had zero T-cells at some point in their life may never repair the gaps in their immune system,” he says. “Their vulnerability to illness may be very different from someone who was treated soon after infection.” This is borne out by studies that show that the likelihood of developing cancer9 or HIV-related brain impairment10 is related much more strongly to a person’s lowest-ever CD4 count than to their current one. “There is also some evidence HIV directly ages cells,” he adds.

So if we take ART, we should stop ageing faster? No, unfortunately. The one class of HIV drugs that virtually everyone on ART has taken are the NRTIs – the nucleoside reverse transcriptase inhibitors. NRTIs prevent HIV’s DNA copying its genes. To a lesser extent, they also interfere with our own genes, especially those in our mitochondria.

Mitochondria are little capsules inside our cells that supply energy. Their genes are vulnerable to drug damage because they lack the error-correction mechanisms of the DNA in our cell nuclei. We’ve largely stopped using the drugs most toxic to mitochondrial DNA – ddI, ddC, d4T and, to a lesser extent, AZT – but the damage may be persistent, and all NRTIs may cause some mitochondrial toxicity.

Mitochondrial toxicity causes a whole range of effects seen in people with HIV – fat redistribution, type 2 diabetes, liver malfunction, nerve damage, damage to blood vessels.

What to do about it

By now, you may be feeling anxious. But there are things you can do to reduce the likelihood of age-related conditions.

“Exercise and diet are key,” says Mike. “In many ways, treated HIV and type 2 diabetes resemble each other. They can be exacerbated by an unhealthy lifestyle, but the burden of disease they impose can be reversed by adopting a healthier one.”

Our capacity for aerobic exercise is reduced when our mitochondria are damaged,11 but, on the other hand, exercise can actually gee-up slow mitochondria,12 at least in people with diabetes.

These are not the only risk factors that are under our control. One study in 2009,13 and others since, have estimated that the disease burden in people with HIV with undetectable viral loads could be halved if people maintained a healthy weight; controlled their carbohydrate intake and avoided diabetes; had their blood pressure monitored and took medication if it was too high; avoided hepatitis C and were vaccinated against hepatitis B; and stopped smoking. These measures would make even more difference in the over-50s.

So that’s what your doctor would prescribe. But what can you do if you’re the patient?

Always double-check what the doctors say

David is 67, a retired antiques dealer. He has had health scares, and he thinks that people like him need to monitor their health more closely than HIV-negative people might – and to learn how to get what they want out of the NHS.

“I do believe that people with HIV may present with diseases of ageing in advance of others: I think our health is often a little ‘off-colour’, he says. “I also think however that older people with HIV, far from being vigilant, may present with symptoms later, because they think, ‘It’s just HIV’.”

In his case, anal screening had established he had AIN stage 2 – anal intraepithelial neoplasia, a change in the cells lining the anus that may, if left unchecked, develop into cancer.

“I felt things weren’t right down there,” he says. “The pathologist scheduled me for a biopsy but told no one he was on leave and further appointments kept being cancelled. Eventually, when I insisted on an appointment and was seen, they told me I’d have to have immediate surgery and radio- and chemotherapy.“I phoned one of the HIV consultants who in turn got me to talk to a cancer specialist at another hospital who said ‘Don’t be ridiculous, we can manage this’.” David didn’t have to have surgery.

Conversely, he says, he’s sometimes had to insist on medical intervention. “I’ve had skin cancer before and a few years ago I was getting a one-sided headache and a feeling I had persistent sunburn. I took it to the on-call registrar at my HIV clinic and she said ‘Yes, it’s basal cell carcinoma [the most common form of skin cancer], and we’ll see you in two months’. I said ‘If this is cancer, get it out of me now!’.”

The key, he says, is “always to get a second opinion”. He doesn’t mean by this to set doctors against each other – unless necessary – but, for instance, to get checked out regularly by your GP too.

Use your GP

“I see my GP practice every three months or so. You can nominate which doctor you want to see. GPs will do things that HIV clinics don’t – such as automatically check your blood pressure.”

Mike Youle agrees with this. “I took a long time to engage with GPs, but HIV clinics won’t be able to do everything for older HIV patients.” He also thinks all HIV clinics should be setting up age clinics, along the lines of London’s Chelsea and Westminster Hospital, which already runs a specialist age and HIV clinic.

David says: “There should be a standard set of good-practice guidelines on what to do for older HIV patients, with a user-friendly version for patients. And there should be a special appointment at the HIV clinic when someone is 50, and maybe every five to ten years thereafter, to do a comprehensive ‘MOT’ and check for anything likely to cause trouble.”

To be really comprehensive, a health MOT would also need to include psychological and cognitive tests. David thinks the psychological and socioeconomic situation of many older people with HIV is crucial to their health.

Depression, anxiety and ageing

Studies show that there is an association between high cholesterol and Alzheimer’s disease,14 and that diabetes and Alzheimer’s may be caused by similar metabolic disturbances, to which HIV may add its own kind of impairment. But David feels a lot of ill-health has social and psychological causes. “There are a lot of isolated, mildly depressed older people out there – especially men – who don’t look after themselves and for whom life has little to offer.”

There’s even research that shows that depression and anxiety may have a direct effect on genes that control ageing - and levels of depression in older people with HIV are scandalously high.

Recently, a study in San Diego, California, compared old with young and HIV positive with negative, in a group of 179 locals.15 It got them to complete separate questionnaires on how easy they found it to deal with tasks of daily life, and assessed their overall emotional quality of life and their burden of diseases common in older people.

It found that daily functioning was worse in people with HIV, especially older people, and that HIV had a stronger effect on ability to carry out daily tasks than age. But the only factor in the HIV-positive over-50s that predicted poorer functioning in every domain, especially compared with HIV-positive under-40s, was major depressive disorder, sometimes called ‘clinical depression’.

That means depression strong enough to stop you getting out of bed. The prevalence of current major depression in the HIV-negative participants, regardless of age, was 2.3%. In HIV-positive people over 50 it was ten times as common – 24.5%.

This is of particular concern because it does not reflect the experience of most people as they age. Older people are generally happier people. In 2010, a study in New York asked nearly 350,000 18- to 85-year olds how stressed, angry, worried, sad or happy they were.16 The peak age for being happy was 70, and the peak age for overall wellbeing was 85; perhaps the only reason it wasn’t older is because that’s where the survey stopped. Other research shows that the patterns holds true for western and eastern Europe, Latin America and Asia.17

There is also research – among HIV-negative people – that indicates a direct link between emotional upset and length of life.18 Not because it makes people smoke or drink or kill themselves, but because stress directly harms genetic material that protects us against the effects of ageing.

Given levels of depression as high as those seen in the San Diego study, it could mean that a large portion of the reduced life expectancy seen in people with HIV can be directly laid at the door of isolation, stigma, shame and worry. And the key to a longer life might be to make friends, stay proud, fight stigma and stay calm.

A sense of belonging

Mike Youle says: “It’s a cultural thing, operating at several levels. One is that older people feel on the shelf generally: the best thing you can do for them is offer the chance to work. Secondly, there’s not been a place for retired men to go to. The Women’s Royal Voluntary Service is now actually doing some work with older single men and how to engage them... Thirdly, there’s never been any model for how you age gracefully as a gay man, not even in the pre-HIV days.”

One thing he’d like to see, he says, “is one of the best things I think the Terrence Higgins Trust ever did – buddying. This time, not for people with AIDS, but for older people with HIV.”

One recipe: friends, dancing and good food

John might be an example to follow. The 70-year-old retired lecturer in earth sciences has regrets, in particular the loss of his beloved partner of 25 years, Nick, who died of AIDS in 1993, and that he has not found another to be with in later life.

In other ways, however, his life is very full. “I love London and would not want to move out of it, even though most of my friends have,” he says. But he maintains a group of friends, gay and straight, men and women, and visits one nearly every weekend.

He also has his weekly exercise workout. “Every Thursday I go to Heaven gay disco in London and dance for a couple of hours. It keeps me fit and I’m surrounded by 20 year-olds who are nice and friendly; I have been with younger people most of my working life and I’m sure this helps me keep a youthful outlook.” Having said that, realising dancing didn’t exercise his upper body, he’s just bought a set of dumbbells.

He is very concerned about his diet, not in a faddish way, though he does worry about the constantly changing dietary advice. “But I do always cook myself a proper meal in the evening and will have a large glass of single malt Scotch whisky – never more – to speed me along while I’m doing it.”

Like David, he believes in the value of getting second opinions and questioning medical decisions. He has reason to: he has multi-class drug resistance and lipodystrophy, and had lactic acidosis that nearly killed him, partly because doctors attributed all the acute symptoms he was suffering from to one drug, nevirapine, when in fact most were caused by another, ddI. John’s health picked up when he decided to follow his original “wonderful” HIV doctor to his new clinic.

“Doctors, and especially GPs, don’t pick things up,” he says. “You have to push things in front of them”. Like David, he sees a GP practice where there are two nominated doctors he chooses to see.

Also like David, he’s had more problems with inexperienced staff. “I went [to my HIV clinic] and my regular doctor wasn’t there. I saw a registrar who said ‘Your results are fine’, implying I could leave, but when I asked what my viral load actually was, it was 220. I said ‘Excuse me, it’s supposed to be under 50!’ and demanded another test. This was in fact the first sign of my drugs failing, as subsequent tests showed higher viral loads. I’m now on a new regimen which I’m pleased to say is working well.”

He keeps himself mentally alert, saying “I read The Economist rather than sit there doing Sudoku.

“I think staying positive and surrounding yourself with people who like you is the key,” he concludes, “and especially retaining an interest in helping others. Some older people get very self-absorbed. I think every time you take an interest in someone else, it prolongs your own life. Ask not what they can do for older people like you, but what an older person like you can do for them.”

References

Health Protection Agency HIV in the United Kingdom: 2011 report. See www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131685847

See www.aidsmap.com/page/2108880

Nakagawa F et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS 6(3):335-43, 2012.

May M et al. Impact of late diagnosis and treatment on life expectancy in people with HIV-1: UK Collaborative HIV Cohort (UK CHIC) study. BMJ 343, 2011.

Hasse B et al. Morbidity and aging in HIV-infected persons: the Swiss HIV Cohort Study. Clin Infect Dis 53(11): 1130-1139, 2011.

Klein D et al. Hospitalization of CHD and MI among Northern California HIV+ and HIV- men: additional follow-up, changes in practice and Framingham risk scores. 13th Conference on Retroviruses and Opportunistic Infections, Denver, abstract 737, 2006.

Sogaard OS et al. Hospitalization for pneumonia among individuals with and without HIV infection, 1995-2007: a Danish population-based, nationwide cohort study. Clin Infect Dis 47:1345-1353, 2008.

Smith R et al. Dying of AIDS in the era of HAART: a national audit. 17th annual British HIV Association conference, Bournemouth, abstract 012, 2011.

Worm S NADM and Immunosuppression: The D:A:D Study. 19th Conference on Retroviruses and Opportunistic Infections, Seattle, abstract 130, 2012.

Heaton R et al. HIV-associated neurocognitive impairment remains prevalent in the era of combination ART: the CHARTER study. 16th Conference on Retroviruses and Opportunistic Infections, Montreal, abstract 154, 2009.

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It was my first year attending the Gay Men’s Health Summit this November (the 8th annual organized by the Community-Based Research Centre for Gay Men’s Health) and the organizers dished out an impressive program.

While efforts to de-stigmatize HIV testing have been encouraging everyone who has ever had sex to get tested (an important effort!) HIV remains a heavy burden for the gay community, an issue conference organizers insist needs to be brought into the light. While in Vancouver it is estimated that 1 in 1,000 people have HIV in the general population, when you look at just the gay male population, the number is 1 in 5. Needless to say, it remains as important as ever to gather to discuss how HIV is a key health concern for the gay men’s community. To keep the discussion going, I connected with Jaime Forrest (below left), the coordinator of the Momentum sexual health study, to hear his reflections on what was presented at the Summit.

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Andrea Langlois (AL): What does this year’s summit theme “Reconsidering the social determinants of health” mean to you?

Jamie Forrest (JF): Reconsidering the social determinants of health is about highlighting and recognizing the important social drivers of gay men’s health inequities. We are not all equal in our risk for any given health condition. There are social, cultural and economic factors that make us all more or less susceptible to illness. Research and practice that ignores this, by not considering the unequal distribution of access to resources and knowledge that protects our health, will be flawed in its approach. This year’s conference importantly reminded us that broadening the discourse to include elements of the social determinants of health framework is crucial to working towards a better and more holistic understanding of gay men’s health.

AL: A new (to me at least!) acronym that got more action than others at the Gay Men’s Health Summit was “UAI.” What does this acronym mean and what does it say about the focus of some HIV prevention research?

JF: Yes, the acronym “UAI” definitely was floated many times at the Summit! The acronym UAI stands for Unprotected Anal Intercourse. The term UAI historically comes from the field of epidemiology, the study of population health. In epidemiology, researchers use UAI as an outcome measure when trying to better understand what factors are associated with transmitting or acquiring HIV. However, this is an imperfect measure of risk of transmission. There are many forms of unprotected anal intercourse that vary in risk. Controlling for relationship status and sex with regular versus casual versus anonymous partners as well as partner serostatus is therefore important for researchers to account for in describing risk associated with UAI.

AL: Methods for measuring sexual altruism and HAART optimism were presented by Allan Lal and Ashleigh Rich, and Sarah Chown provided an overview of what gay men’s health literature says about resilience – what do these approaches offer to researching the social drivers of HIV within gay communities? Or not?

JF: Let me first remind folks that HAART optimism is the belief in/reliance on new HIV treatments, and how a lowered perception of risk may be associated with increased risk behaviour. I think that HAART optimism and resilience can be linked in a number of complex ways. Sarah Chown told us that resilience can be a strength in some contexts but can heighten vulnerability in others. In terms of exposing people to vulnerability, hiding behind optimism of HIV treatment and prevention innovations may be an effort to shield ourselves from actual sexual risks. For example, a belief in HIV treatment as a prevention tool may lead to reliance on “low viral loads” or as protection from transmitting HIV. More importantly though, we learned from these presenters that the ways in which we express HAART optimism and resiliency are both complex and unique and we must consider this when understanding sexual health in our communities. There was certainly agreement at the Summit that HAART optimism and the concept of “resilience” can serve to depoliticize gay men’s needs and that building resilience at the community level is an essential component to prevention.

AL: This year’s Summit included workshops on rebuilding the grassroots gay men’s health movement (Robert Birch) and several presentations mentioned the importance of community in building the health of a community, does this represent a shift in the direction of health programming for gay men?

JF: Community, in a broad definition, has always played a crucial role in the gay men’s health movement, but there are still ways in which our strength as a collective will accomplish more than our individual parts. This is especially true in a changing social landscape where gay men are more geographically decentralized than ever before. To keep our community movement building, we need to adapt to the new ways that gay men are seeking out others, and to pay attention to what gay men are looking for when we do this. Better community programming will need to include participation online, including social media and networking sites and mobile apps. Community building will also require us to take a more inclusive approach to gay men’s health that includes the social, sexual, mental and physical health domains important to gay guys today.

AL: In his plenary presentation, Dr. David Brennan spoke about health outcomes associated with viewing pornography, and Jody Jolimore from the Health Initiative for Men, Robin Parry from Qmunity and Del Stamp from Priape Vancouver shared thoughts on barebacking in porn. What can we conclude about porn and gay men’s health?

JF: Porn is a part of nearly every gay man’s life. Dr. Brennan shared research findings that show some positive outcomes associated with viewing pornography, such as a decrease in sexual risk that may be associated with viewing certain porn at particular ages of development, but that there may be some negative body image associated outcomes as well. Robin, Jody and Del’s panel engaged the audience in thinking about bareback porn, both professional and amateur, and the influences that watching porn may have on a person’s engagement in sexual risk. My conclusion is this — as something so much a part of every gay man’s world, we must continue having conversations about both the positive and negative outcomes associated with the frequency and content of the porn we watch.

AL: Okay, now just for fun, what was the social highlight of the Summit this year? On the fashion front I definitely saw a lot of checked shirts and skinny ties!

JF: Skinny ties were definitely in this year, Andrea. Next year, I’m hoping to see more suspenders and bow ties at the best-dressed academic conference in BC. The social highlight of the conference has always been the wine night after the opening. It’s a great opportunity to connect with great folks doing great work in gay men’s health across Canada. Another great conference under our designer belts!

Questions? Feedback? Get in touch!

Andrea Langlois

Community-Based Research Manager  This email address is being protected from spambots. You need JavaScript enabled to view it.

Follow Andrea on Twitter at @PAN_CBR

This article first appeared on the website of the Pacific AIDS Network here.