This Week in HIV Research: The Mind Matters

While PrEP, HIV treatment as prevention, and condom usage are all highly effective HIV prevention methods, they are not enough by themselves to address every factor associated with ongoing HIV transmission, a study recently published in the journal AIDS indicated.

The research involved an open-label extension to the French-Canadian ANRS-IPERGAY trial of PrEP on demand among MSM. Although participants tended to consciously choose the partners and circumstances under which they had condomless anal intercourse while not using PrEP, that HIV risk management approach was not always effective, the study found.

Overall, 19% of the 1,253 instances of anal intercourse reported by 319 participants did not include condoms or PrEP. Eighty-five percent of these encounters were with main partners, and 47% with partners the participant believed to be HIV-negative.

Unprotected sex was more likely if the participant had had a depressive episode in the prior year, had more frequent sexual encounters, or had been drinking alcohol before intercourse. Conversely, sex without condoms or PrEP was less likely when casual or multiple partners, a partner with a detectable HIV viral load, or one of unknown serostatus were involved.

Other studies have shown high rates of seroconversion from main partners because of non-exclusive sexual relationships, and relatively infrequent HIV testing increases the odds that a person who identifies as HIV-negative has seroconverted without their knowledge, the researchers suggested.

ANRS-IPERGAY participants are not necessarily a representative sample of MSM, and the potential impact of stigma on sexual behavior was not explored, study authors cautioned. Nonetheless, results show that mental health issues, such as depression, need to be addressed in the context of HIV prevention, they concluded.

Once people seroconvert, they are more likely to be virally suppressed and have higher trough CD4 cell counts if they see the same health care provider over time, an analysis of data from the Illinois Medical Monitoring Project published in The American Journal of Managed Care showed.

The data were derived from 1,584 people in Illinois who were participants in a Centers for Disease Control and Prevention-sponsored supplemental surveillance system that combined interviews with medical record abstractions. Of those 1,584 people, only 537 (34%) answered interview questions that specifically focused on consistency in HIV care providers. All participants received HIV medical treatment.

The study found that 79% of participants were virally suppressed (per their most recent test result) and 85% had a CD4 count of 200 or higher. People who reported having a consistent HIV health care provider were four times as likely to be virally suppressed and to have a CD4 count of 200 or higher compared to those who reported not having a consistent HIV health care provider.

Seeing the same health care professional at each visit not only improves the patient-provider relationship, but also means consistent health care access, which in itself may improve overall health, study authors noted.

HIV outcomes were also better among those living in Chicago compared to the rest of the state, likely due to better access to services and transportation. Conversely, outcomes were worse among heterosexuals compared to MSM, possibly because of the relative dearth of HIV prevention and treatment programs intended for straight people, study authors wrote.

In addition, as shown in other studies, unmet social needs were associated with worse HIV outcomes. Unsurprisingly, race, age, and health insurance access also factored into outcomes, with Black participants faring worse than non-Black participants and younger participants faring worse than older participants.

The study authors recommended policy interventions to ensure consistent patient-provider relationships, social services to address non-medical needs, and programs targeted at heterosexuals.

For some people, religion or spirituality may be associated with a greater likelihood of using condoms or PrEP to prevent HIV, a survey of studies on the subject published in PLOS One found.

Most of the 29 studies surveyed (41% of which were conducted in Africa and 48% in the U.S.) dove into the relationship between attendance at religious services and condom use. Little research about spirituality beyond major organized religions was conducted, nor was stigma considered.

A positive association was found between HIV prevention activities and religiosity, faith, or spirituality in 48% of the studies surveyed; this relationship was mediated mainly through social influence.

Other reports have suggested that HIV prevention beliefs and practices may be related to certain denominations, specifically to non-fundamentalist theologies. Given the shift in denominations in many countries with a high HIV prevalence, such research should be considered when devising HIV prevention programs in the context of religious beliefs and practices, survey authors concluded.

The authors also recommended further research that includes spirituality beyond organized religion—and research that also considers the effect of stigma on PrEP uptake and other HIV prevention activities.

Universal access to direct acting antivirals (DAAs) can keep hepatitis C (HCV) reinfection rates low within communities, even in the absence of behavioral changes such as using condoms during anal intercourse and not sharing equipment for injection drug use, an Australian study published in AIDS showed.

Researchers followed 272 people (96% men) living with both HIV and HCV over a median of 2.91 years. Rates of condomless anal intercourse with casual partners and rates of injection drug use remained stable over that period, at 39% and 46%, respectively, by study end. Specific injection behaviors, such as the use of unsterile needles or equipment sharing, also remained unchanged during that time.

The HCV reinfection rate was 1.05 per 100 person-years, compared to as much as 13.4 per 100 PY in Europe.

In Australia, cumulative HCV treatment uptake was 91% after the country made DAAs available to everyone without restrictions in early 2016. Among people who inject drugs specifically, the uptake was 88%; among people engaging in unprotected anal sex, it was 89%. Such high treatment rates lead to a “treatment as prevention” effect in which there is less HCV to spread, study authors noted. (Notably, Australia’s HCV epidemic is small relative to its population, with an estimated prevalence of less than 2,500 people, the researchers stated.)

Although European modeling studies had found the need for behavioral risk reduction in addition to DAAs, “our data highlight the potential public health impact of a universal DAA access program with high treatment uptake in an urban Australian population without risk behavior modification,” study authors concluded.