Viral load and HIV transmission workshop

1. Viral load and HIV transmission workshop Daniel Pugh (GMSH) and James Wilton (CATIE) HIV Testing Conference June 12th and 13th, 2013

2. Goal • To improve your ability to answer questions and provide messaging on viral load and HIV transmission risk

3. Agenda • Overview of the research • Challenges in communicating/messaging • Scenario-based group work

4. An overview of the research on viral load and HIV transmission risk James Wilton Biomedical Science of HIV Prevention Coordinator CATIE

5. The basics on viral load and HIV transmission Viral load refers to number of virus in the bodily fluids of someone living with HIV Copies of HIV per ml of fluid (copies/ml) Measured in the blood to monitor the effectiveness of treatment Other bodily fluids not routinely measured Viral load in different bodily fluids correlated, but not perfectly HIV transmission occurs after an exposure to a fluid that contains HIV Not all exposures lead to HIV infection and some have a higher/lower transmission risk than others

6. The basics on viral load and HIV transmission Viral load in fluid is most important predictor of whether an exposure leads to infection Higher blood viral load associated with an increased risk of sexual HIV transmission 10-fold increase in viral load  2-3 fold increase in HIV risk The high viral load during the first 3-6 months after becoming infected with HIV increases risk of HIV transmission by 26-fold Treatment can reduce viral load to undetectable levels and this can reduce the risk of HIV transmission

7. Questions • How much can treatment reduce the risk of HIV transmission? • What is the risk of HIV transmission through condomless sex when undetectable in blood?

8. How much can treatment reduce the risk of HIV transmission? • HPTN 052 randomized controlled trial • Treatment reduced risk of HIV transmission by 96% (26-fold) among heterosexual serodiscordant couples • Couples provided with ongoing adherence and prevention counseling, viral load monitoring, STI testing and treatment and free condoms • What is risk-reduction for couples who don’t receive, or have access to, these services? • Did condom use influence this 96% risk-reduction? • Couples reported mostly having vaginal sex • What is risk-reduction through other routes of HIV transmission, such as anal sex and injection drug use?

9. "there is reason to believe that early initiation of ART for HIV prevention will benefit MSM, transgender women, and others who have anal intercourse, although the magnitudeof the effect may be different from that observed in serodiscordant heterosexual couples”

10. http://www.oppositesattract.net.au/

11. What is the HIV risk through condomless sex when undetectable? • Consensus that risk is not zero • Undetectable does not mean there is no virus • Can sometimes be detectable (although lowered) levels of virus in genital/rectal fluids when undetectable in blood • More common if inflammation is present at genitals/rectum (e.g. STIs or vaginal conditions) • Unclear if this virus has implications for HIV transmission • Risk may not be the same for all types of sex • Baseline risk associated with activity may play a role • For example, on average, the risk of HIV transmission through receptive anal sex is up to 20-times higher than other types of vaginal and anal sex • Unclear whether this applies to the risk when undetectable

12. What is the HIV risk through condomless sex when undetectable? • Recent systematic review found no HIV transmissions published in the literature among heterosexual serodiscordant couples where HIV-positive partner had undetectable viral load • HOWEVER, couples in review reported using condoms the majority of the time • For example, 96% of participants in the HPTN 052 study reported using condoms everytime they had sex • No studies among same sex serodiscordant couples • One case report of HIV transmission between two men when viral load undetectable; some anecdotal (but unconfirmed) reports

13. http://www.partnerstudy.eu • “The Partner study is enrolling couples where one partner is HIV positive and the other is HIV negative. This new study is looking at the risks of HIV transmission when someone is taking effective HIV treatment” • “This new study particularly focuses on partnerships that do not always use a condom when having sex.”

14. Coming to a consensus • E.g. British HIV Association (BHIVA) position paper • Risk of HIV transmission through vaginal/anal sex when undetectable is “extremely low” when following conditions are met • Viral load has been undetectable for at least 6 months • Viral load is monitored on a regular basis • There are no STIs in either partner • Other examples

15. Questions • How much can treatment reduce the risk of HIV transmission? • What is the risk of HIV transmission through condomless sex when undetectable in blood?

16. Challenges • Communicating risk • Absolute vs. relative risk • Percentages? Qualitative expressions? • Per-act vs. cumulative risk • Uncertainties and research gaps • Messaging on condoms • Context

17. Considerations for high risk populations (MSM) – messages into real world Daniel Pugh Knowledge Transfer Exchange Coordinator GMSH

18. Gay men continue to represent almost 50% of HIV infections in Ontario and Canada…. We need more research that speaks to gay men in order to respond effectively to HIV transmission!!!!

19. GMSH resource • Intended audience: guys having casual and anonymous sex vs. those in a closed/”monogamous” relationship • Not to be used as a legal resource – seek consult from HALCO or Canadian Legal Network • Sex positive and harm reduction valued

20. What DO we know? (HPTN 052) • Condoms + UVL = almost NO infections  • Treatment adherence is good for overall health and well-being! • Treatment reduces RISK of transmission; excitement, less stress? • Condoms still PREVENT transmission – no change there! • Complimentary prevention services (pre/post counseling, STI screening, condoms, VL, etc.) are most ideal

21. NOT studied/implications for gay men: • Casual, anonymous sex/hook ups • Unknown HIV status (20-25%) • Acute HIV infection – higher VL • Impact of STIs (syphilis and gonorrhea) • Susceptibility of anal sex vs. vaginal sex • VL in semen vs. blood • Treatment adherence, treatment resistance • Disclosure and criminalization

22. Ask ourselves: How do we define and educate about RISK?

23. Outreach messages • Guys having a hard time using condoms • Talk about it • HIV stigma • Condomless sex = test ASAP, inside/outside window period • Dipping/withdrawing • How we feel x the sex we’re having • Guys having condomless sex with casual/anonymous partners • Sero-sorting • Strategic positioning • Poppers • Regular STI/HIV testing/screening – signs/symptoms

24. Bottom line: • HIV treatment reduces effects and transmission of HIV • Condomless sex happens – how do we minimize risk? • We need more research...esp. for trans guys having front hole sex and implications of HRT?! • STI – higher risk with casual/anonymous sex and impacts VL • Treatment resistant syphilis and gonorrhea • Plan ahead: think about different strategies • Have fun, be creative!

25. Group work 10 minutes to review and discuss YOUR scenario 

26. Scenario-based group work: • What level of risk do you perceive from this scenario? • What are the key messages you should communicate to the client(s)? • Was there any discomfort or uncertainty that arose for you in this scenario? • Any contentious issues in your small group discussion? • Additional concerns, questions you would want to know?

27. Case Study 1 Juan comes into your clinic for his annual HIV test. He mentions he has been in a year long, closed/ "monogamous" relationship with Adam who is HIV positive.  They've been using condoms during sex but Juan mentions he and Adam want to stop using condoms because Adam has an undetectable viral load after being on Atripla for the past year and a half.  Their desire comes from the frustration that condoms create a barrier to their intimacy…

28. Case Study 2 Rahim is HIV positive and ‘undetectable’. He frequents the local bathhouse for sex but doesn’t use condoms because he’s been assured he has an undetectable viral load. He comes to see you for his routine STI screening…

29. Case Study 3 Amanda (HIV positive) and Sergio (HIV negative) are in an open relationship.  They love to explore other sex partners together.  They insist on condoms when having sex with other people but do not use condoms together because Amanda is on treatment.  They have come to see you for their routine testing appointment…

30. Case Study 4 Cynthia just ended a relationship with her boyfriend of three years after learning that he's had multiple sex partners (guys and girls) behind her back.  Cynthia is concerned about her health (neither she nor her ex was tested for HIV within the last two years) and feels like she is presenting symptoms of HIV or an STI. It has been confirmed that one of her ex’s sex partners was recently infected with HIV…

31. Case Study 5 Chen and Roger are two guys in an open relationship. Chen is positive and undetectable, while Roger remains HIV negative at this time. Although they do not have any specific agreements about how to play with others, Chen does not use condoms as a result of his undetectable status. Instead, Chen (and Roger) often use strategies like sero-sorting (finding other poz guys) or strategic positioning (Chen as bottom) to reduce the transmission/acquisition of HIV…

32. Resources for you: • www.thesexyouwant.ca • www.catie.ca • www.positivelite.com • www.new2ontario.ca • www.actoronto.org • www.halco.org • www.aidslaw.ca • www.ouragenda.ca - coming soon!

33. Thank you! James Wilton jwilton@catie.ca Daniel Pugh dpugh@gmsh.ca