Scary News About Secondary Transmission

Two recent items in the news, taken together, may have troubling implications about HIV transmission and suggest new action among primary care providers who have at-risk patients. One is a study published in March in the journal AIDS, which major media outlets covered extensively. The other is the recent recommendation from a Food and Drug Administration (FDA) committee for approval of the first drug to prevent HIV in healthy people. 

The study, from researchers at Boston University, evaluated HIV levels in blood and seminal fluid in 101 sexually active men who have sex with other men (MSM) and who were receiving  highly active antiretroviral therapy (HAART).¹

Researchers found detectable levels of the virus in the blood of 18% of the men, but in 30% of the semen samples. In addition, a quarter of the men with undetectable levels of the virus in their blood had detectable viral levels in their semen with copy numbers ranging from 80 to 2,500. Men were more likely to have viral levels in their semen if they had a sexually transmitted infections (STI)/urethritis, levels of the inflammatory marker TNF alpha, or engaged in unprotected anal sex with an HIV-infected partner.

This finding may help explain a disturbing trend in recent years-the skyrocketing rate of infection in gay and bisexual men, particularly African-American men. The Centers for Disease Control and Prevention reports that between 2006 and 2009, there was a 48% increase in new infections among young (13-29) black MSM. Gay and bisexual men overall account for the greatest number of new infections in the United States, responsible for 61% of the estimated 52,000 new infections that occur each year.²

The reasons are complex. They include the high prevalence of HIV in this population, lack of knowledge about their HIV status, and, most concerning, complacency about their risk of transmission since they did not experience the early days of the epidemic and since they may believe that ART protects them from transmission.²

There is good evidence when patients use their HIV medications properly and have undetectable viral loads, the risk of secondary transmission of HIV is very low.^3,4 However, as the Boston study demonstrated, there may still be a significant risk of transmission if men do not use condoms during intercourse, or if they engage in other risky sexual behavior. The higher risk in men with an STI is particularly concerning given evidence of rising STI infections this population.⁵

There is also good evidence that MSM often engage in unprotected sex. One of the largest studies to evaluate condom use among MSM in the US found that just a third of anal intercourse acts involved a condom.⁶ Meanwhile, HIV-infected men are less likely to use condoms during oral sex.⁷

The findings of the Boston study also have implications if the first ART therapy is approved to prevent viral infection in healthy people. As noted earlier, an FDA committee recommended in early May that the agency approve the fixed-dose medication Truvada (enofovir/emtricitabine) for that purpose. The ground-breaking study found that daily use could reduce the risk of HIV infection by 90%.⁸

If HIV-infected men and their partners assume protection from the drug, will they be less likely to use condoms? As noted earlier, there is already evidence of complacency about viral transmission in people taking ART. The Truvada study also found that only 10% of men took the drug as directed, raising concerns that its use for prevention could backfire.⁸ What It All Means

The message of the Boston study, coupled with growing evidence of risky sexual behaviors among MSM, is that primary care clinicians should increase and improve communication with HIV-infected patients about safe sexual practices-even those on HAART who are in monogamous relationships.  The FDA advisory panel recommended a detailed education effort for providers, including primary care physicians, likely to prescribe the new combination. But it focuses on testing and followup, not on how they can interact effectively with patients to increase the likelihood of adherence to the drug regimen as well as to other effective preventive strategies.

Simply telling patients to use condoms doesn’t work, for instance. Instead, clinicians need to incorporate other forms of communication such as motivational interviewing and open-ended questioning, according to longstanding recommendations from the Centers for Disease Control and Prevention on how to conduct such conversations.

Providers need to use language their patients can understand, which is not blaming or demeaning, but “normalizing,” i.e., showing patients that they are not alone in their reluctance to use condoms. For instance, say: “I know it can be difficult to use condoms with every act of sex. Do you have any challenges with condom use?”⁹

Another recommendation is that clinicians use the Five Ps in their counseling:

1.    Partners
   “Do you have sex with men, women, or both?”
    “In the past 2 months, how many partners have you had sex with?”
    “In the past 12 months, how many partners have you had sex with?”

2.    Prevention of pregnancy (for men in heterosexual or bisexual relationships)
   “Are you or your partner trying to get pregnant?”
   If no, “What are you doing to prevent pregnancy?”

3.    Protection from STDs
  “What do you do to protect yourself from STDs and HIV?”

4.    Practices
 “To understand your risks for STDs, I need to understand the kind of sex you have had recently.”
 “Have you had vaginal sex, meaning ‘penis in vagina sex’”?
(If yes, “Do you use condoms: never, sometimes, or always?”  “Have you had anal sex, meaning ‘penis in rectum/anus sex’”? If yes, “Do you use condoms: never, sometimes, or always?” “Have you had oral sex, meaning ‘mouth on penis/vagina’?”)

For condom answers:

If “never:” “Why don’t you use condoms?”
If “sometimes:” “In what situations or with whom, do you not use condoms?”

5. Past history of STIs

“Have you ever had an STI?”
“Have any of your partners had an STI?”

Additional questions to identify HIV risk include:

“Have you or any of your partners ever injected drugs?
“Have any of your partners exchanged money or drugs for sex?”
“Is there anything else about your sexual practices that I need to know about?”

There is good evidence that these approaches can reduce risky sexual behavior. Given the recent study and the rising number of MSM infections, this is becoming as important today as it was when the virus first struck.
 

1.    Politch JA, Mayer KH, Welles SL, et al. Highly active antiretroviral therapy does not completely suppress HIV in semen of sexually active HIV-infected men who have sex with men. AIDS. 2012.
2.    Centers for Disease Control and Prevention. HIV and AIDS among gay and bisexual men. September 2011;  www.cdc.gov/nchhstp/newsroom/.../fastfacts-msm-final508comp.pdf. Accessed May 16, 2012.
3.    Sheth PM, Kovacs C, Kemal KS, et al. Persistent HIV RNA shedding in semen despite effective antiretroviral therapy. AIDS. 2009;23(15):2050-2054.
4.    Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med. 2000;342(13):921-929.
5.    Centers for Disease Control and Prevention. STDs in Men who Have Sex with Men. November 2011;  http://www.cdc.gov/std/stats10/msm.htm. Accessed May 16, 2012.
6.    Rosenberger JG, Reece M, Schick V, et al. Condom use during most recent anal intercourse event among a U.S. sample of men who have sex with men. The journal of sexual medicine. 2012;9(4):1037-1047.
7.    Dodge B, Schnarrs PW, Reece M, et al. Sexual Behaviors and Experiences Among Behaviorally Bisexual Men in the Midwestern United States. Arch Sex Behav. 2011.
8.    Grant RM, Lama JR, Anderson PL, et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. N Engl J Med. 2010;363(27):2587-2599.
9.    Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports / Centers for Disease Control. 2006;55(RR-11):1-94.

References:

REFERENCES1. Politch JA, Mayer KH, Welles SL, et al. Highly active antiretroviral therapy does not completely suppress HIV in semen of sexually active HIV-infected men who have sex with men. AIDS. 2012

2. Centers for Disease Control and Prevention. HIV and AIDS among gay and bisexual men. September 2011; www.cdc.gov/nchhstp/newsroom/.../fastfacts-msm-final508comp.pdf. Accessed May 16, 2012

3. Sheth PM, Kovacs C, Kemal KS, et al. Persistent HIV RNA shedding in semen despite effective antiretroviral therapy. AIDS. 2009;23(15):2050-2054

4. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med. 2000;342(13):921-929

5. Centers for Disease Control and Prevention. STDs in Men who Have Sex with Men. November 2011; http://www.cdc.gov/std/stats10/msm.htm. Accessed May 16, 2012

6. Rosenberger JG, Reece M, Schick V, et al. Condom use during most recent anal intercourse event among a U.S. sample of men who have sex with men. The journal of sexual medicine. 2012;9(4):1037-1047

7. Dodge B, Schnarrs PW, Reece M, et al. Sexual Behaviors and Experiences Among Behaviorally Bisexual Men in the Midwestern United States. Arch Sex Behav. 2011

8. Grant RM, Lama JR, Anderson PL, et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. N Engl J Med. 2010;363(27):2587-2599

9. Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports / Centers for Disease Control. 2006;55(RR-11):1-94