Positive Prevention Gus Cairns UKC What is it

Positive Prevention Gus Cairns UKC

What is it? Work with/for people living with HIV and AIDS (PLHAs) to prevent the onward transmission of HIV l Gets called both ‘primary’ and ‘secondary’ prevention according to tradition l

Positive prevention makes sense… l l l On an economic and efficiency level: an HIV positive person is involved in every HIV transmission event and has potentially greater ability to ensure transmission doesn’t happen On a legal level: people with HIV are at risk of prosecution for transmission On a human rights level: people with HIV have demonstrably greater sexual health and mental health needs

What might it involve? (International HIV/AIDS Alliance paper, 2003)

Test, test… l CDC in USA calculates that when diagnosed, PLHAs cut risk behaviour by 2/3 l l Universal testing drive: recommended testing all 13 -65 year olds: Washington DC recently extended this to 85 Then what? CDC prevention interventions mention: ongoing case management l focused risk-reduction counselling l medical interventions (leaving these undefined) l support for other psychosocial stressors (leaving these also undefined) l

Test, test… l Lisa Williamson: compared community surveys in London and Glasgow l l About 1/4 of London gay men had never taken an HIV test About 1/2 of Glasgow gay men hadn’t (but younger) Glaswegians 30% more likely to have potentially serodiscordant UAI ‘Opt-out’ HIV testing for people attending STD clinic introduced in Scotland after Strategy But not all HIV+ people get STD checkups or catch STDs l Proportion of gay men with HIV in community in London who were undiagnosed higher (33 to 48%) than in STD patients (25%) Williamson Lisa et al. Increases in HIV-Related Sexual Risk Behavior Among Community Samples of Gay Men in London and l Glasgow: How Do They Compare? JAIDS 42(2): 238 -241. 2006.

Test, test… l The incidence problem l Baltimore black gay men: 48% positive l Two-thirds unaware l 87% of these had tested: 60% in the previous year l London gay men: 11% HIV+, of which 1/3 undiagnosed and 1/5 had previous negative test

l l l Test, test…concs. CDC USA estimates that once diagnosed, PLHAs reduce their risk behaviour by two-thirds: counselling may increase this HIV negative people who get a test and post-test counselling generally don’t change behaviour Universal testing? Difficult to do, who would do it, prob not cost effective (cf. USA) Opt-out testing at GUM essential. One in five people who go for an STD checkup go away with undiagnosed HIV: proportion decreasing, but still too much GP and A&E staff awareness-raising. Only 16% of Africans ever had subject of HIV raised by GP (Mayisha II study) l Community testing drives? l Home testing?

Positive prevention and positive-led prevention l l l It is always easier to reinforce a positive behaviour than change a negative one Some techniques (such as motivational interviewing) based on this idea Programmes should be tailored to help people sustain behaviour that supports good sexual health and relationships, and to address barriers to adopting them (such as fear of disclosure, depression or substance abuse).

What do PLHAs already do? l Pamina Gorbach: JAIDS 42(1): 80 -85. 2006 l l l Study of sexual risk behaviour in 113 newly diagnosed men Two interviews one c 1 month after diagnosis and other at three months Ave. 34% decrease in partner numbers in previous 3 months (7. 9 to 5. 2) Half decreased partner numbers, a third stayed the same, a fifth increased numbers. Condom use increase? No. 59% had UAI at both timepoints: difference was with whom…

Gorbach and serosorting l Among men who had UAI (n = 103): l l l Proportion of UAI partners who were negative had declined 37% in 3 months Proportion who were positive had increased by 188% Proportion of unknown status had halved

Serosorting is… San Francisco Department of Public Health – HIV Epidemiology Annual Report 2004

And in London… Elford J et al. High-risk sexual behaviour among London gay men: no longer increasing. AIDS 19(18) 2171 -2174. 2005.

And in HIV negatives… Sydney study l Casual UAI in HIV negatives (so not ‘negotiated safety’) l restricted to partners of known negative status increased from 12. 5% to 25% in previous six months l Proportion who had UAI with partner of unknown status decreased from 85% to 70% l UAI Mao Limin et al. 'Serosorting' in casual anal sex of HIV-negative gay men is noteworthy and is increasing in Sydney, Australia. AIDS 20(8): 1204 -1206. 2006.

Does serosorting work? Golden M. , CROI 2006 (abstract #163) l New diagnoses among: l l ‘Always’ condom users: 1. 5% l No special precautions: 4. 1% l Tried to serosort: 2. 6% l Condom use 76% effective l Serosorting about 40% effective

Other strategies l ‘Strategic positioning’ = HIV+ on bottom l l l Withdrawal Viral load l l Insertive sex 10 x less risky but not risk-free Evidence of increasing use but 1/8 of gay men who are undetectable in blood have detectable HIV in semen Condoms. l In SUMIT study* 83% of HIV+ gay men used condoms with HIV- or unknown status partners – but inconsistently

Should we promote serosorting? l l Probably not: it means promoting unprotected sex: condom use should always be first choice Doesn’t protect against STDs. Gay men >50 x more likely to get HIV that heterosexuals: HIV+ gay men >50 x more likely to get LGV than HIV- BUT… l Serosorting implies testing l Serosorting implies disclosure …and we should promote those!

Disclose, disclose… l Point A: l l l Point B: l l l Unpublished GMFA survey, basis of ‘Why won’t he tell? ’ campaign: Only 20% of HIV+ gay men disclose before sex, 40% never do, 40% sometimes Bruno Spire, France*: 97% of HIV+ people in a steady relationship eventually disclose and of the other 3%, 2% use condoms We have to help PLHAs get from point A to point B as fast as possible *Spire B et al. Concealment of HIV and unsafe sex with steady partner is extremely infrequent. 3 rd IAS Conference on HIV Pathogenesis and Treatment, Rio. Abstract Mo. Pe. LB 10. 7 P 01. 2005.

Someone who didn’t get (enough) help to disclose

Criminalisation has changed the game l If PLHAs are going to continue to get jailed for transmitting HIV then: l l l We have a legal, social and moral responsibility to help PLHAs not transmit HIV Notions of ‘joint responsibility’ go out the window: we are not jointly responsible if the law says it’s the HIV+ partner who is And since prevention work directed at PLHAs is more efficient anyway, prevention funding must either increase or be redirected to work with PLHAs

This ought to be true. The law says it isn’t.

So what works? (Two meta-analyses, 2006) l Nicole Crepaz, AIDS 20: 143– 157. 2006. l l l Measured ‘sexual risk incidents’ after 12 RCT interventions Significant reduction (43%) What worked: l l l Interventions specifically focused on safer sex… Which also included help with disclosure, self-esteem etc Were intensive Were delivered in a clinical setting or at a voluntary organisation already providing services At least partly delivered by professional counsellors At least partly delivered on a one-to-one basis

What works II l l Blair Johnson, JAIDS 41(5): 642 -650. 2006. 19 RCT interventions Ave 16% increase in condom use Worked better for: l l Younger ‘Motivational*’ or taught behavioural skills (12% condom use increase) or both (33%) Non-gay; but no programme directed at gay men provided both ingredients proven to be necessary Information alone made no difference but helped other components * Motivational = providing things that improved participants’ overall quality of life such as increased social support or selfconfidence.

Quote from Johnson l “Perhaps the most surprising finding of this work is that more than two decades into the epidemic, there have been so few randomlycontrolled trials of interventions that focus in people living with HIV, though there have been literally hundreds of studies conducted with uninfected populations. There is an urgent need for research in this area. ”

BEWARE: what seems to work may not! l SUMIT study, SF and NY, USA* l l l 811 HIV+ gay men randomised to one discussion session or six 3 -hour workshops. Videos, discussion groups, roleplay, freebies They loved it! Very high scores for enjoyment, learning, life changes, new friends Made no difference to behaviour at all. Unprotected sex marginally but non-significantly improved; disclosure got marginally worse *Wolitski RJ et al. Effects of a peer-led behavioral intervention to reduce HIV transmission and promote serostatus disclosure among HIV-seropositive gay and bisexual men. AIDS 19(Suppl 1): S 99 -109. 2005.

What seems to work may not. Why? l l l Used community rather than clinical setting: health not emphasised Emphasis on protecting partners rather than own health. Self-interest works better than guilt. Gain-framed messages (‘you’ll protect others’) rather than loss-framed ones (‘you’ll mess up if you don’t’). Evidence* that loss-framed messages work better with HIV+ people. Peer group structure can be counterproductive. The cautious end up modelling the risk-takers! Too many choices? Maybe one method (condom use, disclosure, serosorting) should be taught at a time. Worked better in SF than NY. Pre-existing community structure and norms matter. *Richardson J. Prevention in HIV Clinical Settings. 13 th Conference on Retroviruses and Opportunistic Infections, Denver, Abstract 165. 2006.

Would mass interventions work for PLHAs? l l l Not if they portray PLHAs as the danger Not if they address them in the third person Where would you put them anyway? Positive Nation?

How about the net?

Questions l l Should we concentrate HIV prevention resources on PLHAs? What methods would work to increase the uptake of HIV testing? What kind of intervention do you think would work best to help PLHAs reduce risk of onward transmission? Given the limited reach and labour-intensive nature of counselling and support-group work, what ‘broadcast’ might work?