Simon Collins

The history of pre-exposure prophylaxis (PrEP) is notable for being a community rather than industry-driven development. This talk will review this history, covering factors that include community demand, study results, regulatory challenges, commercial interests and practical issues of public health. It will also look at some of the controversies that appear to limit broader access, and important changes since US approval for PrEP in 2012. If PrEP had been discovered in the 1980s, the demand for access is likely to have been very different and it would now be universally available. Yet in many health settings, the willingness to include the option of PrEP appears to be inversely correlated with the increasingly impressive data showing its effectiveness. The limitations of condoms are shown in continued rates of new HIV infections in high-risk populations. These rates have remained persistently high for the last decade, even with the dramatic impact of treatment as prevention (TasP)...

Combination antiretroviral therapy has substantially increased life-expectancy in people living with HIV, but the effects of chronic infection on health-related quality of life (HRQoL) are unclear. We aimed to compare HRQoL in people with HIV and the general population. We merged two UK cross-sectional surveys: the ASTRA study, which recruited participants aged 18 years or older with HIV from eight outpatient clinics in the UK between Feb 1, 2011, and Dec 31, 2012; and the Health Survey for England (HSE) 2011, which measures health and health-related behaviours in individuals living in a random sample of private households in England. The ASTRA study has data for 3258 people (response rate 64%) and HSE for 8503 people aged 18 years or older (response rate 66%). HRQoL was assessed with the Euroqol 5D questionnaire 3 level (EQ-5D-3L) instrument that measures health on five domains, each with three levels. The responses are scored on a scale where a value of 1 represents perfect health and a value of 0 represents death, known as the utility score. We used multivariable models to compare utility scores between the HIV and general population samples with adjustment for several sociodemographic factors. 3151 (97%) of 3258 of participants in ASTRA and 7424 (87%) of 8503 participants in HSE had complete EQ-5D-3L data. The EQ-5D-3L utility score was lower for people with HIV compared with that in the general population (marginal effect in utility score adjusted for age, and sex/sexuality -0·11; 95% CI -0·13 to -0·10; p<0·0001). HRQoL was lower for people with HIV for all EQ-5D-3L domains, particularly for anxiety/depression. The difference in utility score was significant after adjustment for several additional sociodemographic variables (ethnic origin, education, having children, and smoking status) and was apparent across all CD4 cell count, antiretroviral therapy, and viral load strata, but was greatest for those people diagnosed with HIV in earlier calendar periods. Reduction in HRQoL with age was not greater in people with HIV than in the general population (pinteraction>0·05). People living with HIV have significantly lower HRQoL than do the general population, despite most HIV positive individuals in this study being virologically and immunologically stable. Although this difference could in part be due to factors other than HIV, this study provides additional evidence of the loss of health that can be avoided through prevention of further HIV infections. UK National Institute for Health Research.

ABSTRACT Objective: To assess the associations of ART use, viral load (VL) suppression and transmission risk beliefs with sexual behaviour among HIV-diagnosed men who have sex with men (MSM) in the UK. Methods: ASTRA is a multicentre UK study of >3000 HIV outpatients in 2011/12. A self-completed questionnaire defined 'unprotected sex with an HIV-discordant partner' (USD) as anal or vaginal sex without a condom in the past 3 months with a partner of negative or unknown HIV status. Transmission risk belief score (TRBS) was classified as 0-2 [2: agree 'when VL is undetectable, a condom is not needed to prevent HIV transmission'; 1: agree 'undetectable VL makes someone less infectious to a sexual partner' 0: do not agree with either statement]. Associations of USD with TRBS, self-reported ART and VL status, and other factors were assessed using Chi-squared tests and logistic regression. Results: Data are available for 2086 MSM [88% white; mean age: 45 years]. 1767 (84.7%) were on ART; of whom 1470 (83.2%) reported VL≤50 c/mL, 148 (8.4%) reported VL>50 c/mL and 149 (8.4%) did not know VL status. TRBS was 0, 1 and 2 for 48.0%, 47.7% and 4.3% of MSM. Prevalence of USD was 14.8% (n=308) overall; 123 of 308 reported receptive anal sex only. USD prevalence increased with higher TRBS [8.2%, 19.4%, 35.2% for TRBS 0,1,2 respectively; p<0.001]. ART use and VL status were also associated with USD. USD prevalence was lower among MSM taking ART compared to those not on ART [13.8% vs 20.1%; p=0.004]. However, among MSM on ART, USD prevalence was higher among those reporting VL≤50 c/mL compared to reporting VL>50 c/mL/unknown (14.7% vs 9.4%; p=0.016). This pattern of association between ART/VL status and USD was similar after adjustment for demographic, lifestyle, and HIV-related factors: compared to MSM on ART with VL<50 c/mL, adjusted odds ratios (95% CI) were: 0.58 (0.38, 0.89) for MSM on ART with VL>50 c/mL/unknown, and 1.25 (0.87, 1.79) for MSM not on ART, global p=0.006. Absence of an HIV-positive stable partner, more recent HIV diagnosis and recreational drug use were also independently associated with USD (all p<0.05). Conclusions: Approximately 15% of HIV-diagnosed MSM report recent USD. Among MSM on ART, self-reported undetectable VL is associated with USD, suggesting that perceived VL status may influence sexual behaviour and condom use. However, prevalence of USD is also high among MSM not taking ART. These findings have implications for prevention strategies among MSM in the UK.

Background It is known that being on antiretroviral therapy reduces the risk of HIV transmission through sex. However it remains unknown what the absolute level of risk of transmission is in a person on ART with most recent measured HIV plasma viral load< 50 c/mL in the absence of condom use. There are no data on risk of transmission for anal sex in MSM when the index partner is on ART.