Monthly Archives: December 2014

What Do We Want? HIV Cure! When Do We Want it?

Now please! In December 2014 I wrote an article in OutinPerth encouraging people to get active for HIV cure research

What Do We Want?-HIV Cure!- When Do We Want It?
Ahead of the July 2014 International AIDS Conference in Melbourne hopes were high that HIV scientists from around the world would unveil the promise of a much anticipated HIV cure. Headlines of imminent breakthroughs that could lead to a cure for HIV have tantalised the community for years. Sensationalist headlines included ” Danish breakthrough for HIV expected within months”(April 2013).

Instead days before the main conference at the Towards An HIV Cure Symposium organised by the International AIDS Society sobering commentary was shared about the rebound of HIV in both of the two patients from Boston (who received a stem cell transplant) and the Mississippi baby (who after acquiring HIV in the womb received HIV meds within 30hours of delivery). Science is about advancing knowledge which is gained both from what does and doesn’t work. Optimistically we now have proof that we could extend the time it would take for HIV to return/rebound from the usual one to 4 weeks to 4,7, and 27months respectively. Progress indeed, but not the immediate cure that so many people hope for. Getting comfortable with the idea of “HIV remission” maybe an intermediate step that we may need to begrudgingly accept as the next step in HIV cure research

Fortunately for humanity HIV scientists are continuing to meet and where possible collaborate with each other. The latest international meeting occurred In October 2014 Washington D.C. at a conference hosted by the USA National Institute of Health titled Strategies For An HIV Cure 2014. Topics included; Gene Editing and Cell Based Strategies, Immune Based Strategies, Social Ethical & Community Aspects of HIV Cure Research and Strategies to Reverse Latency. Science can be dense and complicated, while its flip side reveals inspiration, talent and our best efforts for human advancement.

Most recently on the 28th of November this year Professor Sharon Lewin, Director from the Peter Doherty Institute for Infection and Immunity(and Melbournian of the year 2014) hosted a community roundtable on Building Partnerships For An HIV Cure. Recognition of community and its contribution to cure research is fully acknowledged by Professor Sharon Lewin with an early partnership approach adopted with the National Association of People With HIV Australia along with other essential community partners.

There are some in the community who do not believe that it is worthwhile dedicating resources to a HIV cure research agenda, believing instead that funding is already stretched and may displace resources from treatment and prevention. The logic is very understandable, and we are all challenged with making choices and trading between opportunities. However the history of HIV has shown that short term either/or positions is detrimental to our long run interests, where both/and thinking has delivered to us the stunningly effective idea of ‘Treatment As Prevention’, where people with HIV successfully on HIV medication are non-infectious (although science is waiting for the statistical confidence intervals to improve) the data trend is now well established (HPTN052, PARTNER Study) we have zero/no linked infections from a person with undetectable viral load.

Many people with HIV and the people who love them are frustrated and angry with the current HIV medication paradigm, where people are condemned to lifelong HIV medication. It appears as though the urgency to cure HIV has waned given that almost 95% of people are on benign drugs and expected to live an almost normal life expectancy. Extremely grateful as most people with HIV are, it is easy to look over the fence with envy at advancements in other areas of health like Hepatitis C where almost all can now be cured.

HIV cure research is already beginning to inform us that early treatment facilitates HIV remission and reduces significantly the total amount of HIV that hides and gets into our cells (viral reservoir) and for some like in the VISCONTI Cohort a ‘functional cure’ ( a very low viral load without medication). The word “cure” can illicit emotional responses, some of us are comfortable with a ‘social cure’ (free from HIV discrimination) others are happy with a ‘cure in transmission’ (we have this now when people are successfully on HIV medication with undetectable viral load), but mostly we want HIV remission and aspire to a “full cure” (also known as ‘sterilising cure’ where HIV is eliminated from the body permanently).
To encourage a healthy pipeline of HIV cure research the community will need to activate and build the political urgency and momentum to “END HIV”. If you would like to assist or remain informed of future community events around HIV Cure Research please contact me When do want a cure “NOW!”

Hate Condoms? Ethical Choices Now Include Truvada

Pills to prevent HIV are a must if we are to end HIV, hurry up and get on board!                         The article below was first published in the November 2014 issue of OutinPerth.

Hate Condoms? Ethical Choices Now Include Truvada
Striking revelations occurred last month. Two separate studies on the effectiveness of Truvada to prevent HIV were stopped prematurely, because early results were so good that having untreated participants became unethical.

Truvada is a HIV medication currently used to treat people with HIV. Truvada pills are currently being studied in HIV negative participants as a way of preventing HIV infection, this strategy is known as PrEP (Pre Exposure Prophylaxis).

The PROUD trial is the first of the studies to announce to all participants the opportunity to take up PrEP. The study was set up to discover if the benefit of taking Truvada (daily dosing, single pill) by negative guys would be cancelled out by men using condoms less or not at all. So 545 men were randomised into two groups, all participants were offered regular STI testing, condoms, safer sex support and behavioural survey and monitoring. However one group received Truvada immediately and the second group deferred treatment with Truvada by a year. Although the official results of the study are not expected until early 2015 the results were so effective in the Truvada group, that it triggered an ethical threshold set before the study began, now everyone in the study has been offered Truvada for PrEP.

The second trial titled IPERGAY (400 participants) is exciting because instead of daily dosing of Truvada it attempts an “on-demand” strategy for taking Truvada, which is more applicable to the real world. This study set up to discover how effective Truvada would be if you took two pills 24hours before when you thought you were going to have sex or a minimum of 2hours before (e.g. on a Friday for Saturday night sex). Then, a daily single pill dosing while your shagging away (e.g. for some virile men this could last a week), when you think your finished take two final does 24hrs apart. Mmm Lets make this strategy a bit simpler, essentially before you have sex have some Truvada in your blood system, while romping maintain Truvada in your blood system by daily dosing, when your finished dose yourself for another two days. Simpler still, take Truvada 1day before, during and two days after you actually had sex (2+1+1+1). I think overtime the creativity of gay men will finesse this prevention strategy further. Importantly the effectiveness of Truvada in the trial again triggered the study’s ethical threshold and all participants were offered Truvada.

In the US Truvada has already been approved for the purpose of HIV prevention in gay men who are negative. This happened after the iPrEx trial , and subsequently iPrEx OLE trial both demonstrated 100% effectiveness of Truvada in preventing HIV if you had sufficient amounts of Truvada in your blood. This equated to a minimum of taking Truvada (single pill daily dosing) 4 times a week.

What does this mean for Australia gay men? Currently Truvada is legal and can be purchased at penthouse prices privately through your friendly HIV medication prescribing GP. There are some Australian PrEP trials (e.g. VicPrEP) currently underway to confirm the feasibility and science of introducing PrEP in Australia. Participants of PrEP trails get access to Truvada for free. If like Gough Whitlam you believe in free universal health care for everyone then “it’s time” to advocate on behalf of sexually active gay man. We have a right to choose our preferred method of HIV protection. Next time you attend STI testing start demanding access to Truvada.

The business case is also favourable for using Truvada as a strategy in a targeted way. Consider the simple life time cost of treating someone with HIV ( e.g. 40+years multiplied by $15,000 per year for HIV medication) $600,000 times approximately 1000 new infections every year, that’s $600 million potentially added to the PBS every year. Now consider targeted Truvada to the 1% of highly active gay men (e.g. 2200 times $15000 per year) $33million per year. These highly sexually active men would only have to prevent 55 new infections per year for the government to break even on its investment. These inaccurate playful numbers would not stand up against health economist scrutiny, however the maths is accurate enough to make the point that investment in HIV prevention and HIV cure research creates a massive public health return in time.

Preventable infections with targeted Truvada as PrEP could make a significant dent in the Australian HIV epidemic. Given the international science, delays in the introduction of targeted Truvada is not only potentially unethical it could also be described as a material systemic failure of public health policy in Australia. Some people who struggle with condoms and acquire HIV, would every right to become extremely angry at having been denied Truvada as a prevention option.

Facing the Ice Challenge to Reduce HIV

If we are to end HIV in Australia facing the Ice challenge will be essential. This article was first published in OutinPerth Oct 2014.

Facing the Ice Challenge to Reduce HIV

Cipriano Martinez

Take notice, 85% percent of men believe ice significantly contributed to behaviour which led to acquiring HIV.

Although this recently reported survey study of 200 people, conducted by the Prahran Market Clinic (Melbourne) can at most only be suggestive because of the very small numbers. For the 65 respondents, who were diagnosed with HIV between 2011-13, the negative consequences of ice behaviour is clear.

Dr Eu, who is located at the clinic explained that using ice (Crystal Methamphetamine) can lower inhibitions and remove the ability to make rational decisions.

The profile screen pages of Perth’s hook up scenes online and on mobile apps frequently make reference to chem sex, wired, party n play (pnp), cannabis (420), oh and lets not forgot the amyl guy too.

Suffice to say that gay boys have been using substances well before HIV came onto the scene in the early eighties. There are many varied reasons why people use alcohol and other drugs, though predominantly it’s used for sex, and the complexity of meaning and emotion attached to the experience, like desire, intimacy, connection, pleasure, to be lost in a moment, to be in control or out of it.

The UK recently highlighted the connection between recreational drugs, sex and living with HIV, in a study called ASTRA (Antiretroviral, Sexual Transmission Risk and Attitudes).

In this large study of 2248 people with HIV, almost 70% where men who had sex with men, most of whom identified as gay, found that 7% of respondents had used ice in the past 3 months. Approximately 38% of all study participants had a detectable viral load (more than 50 HIV copies per millilitre of blood).

The Australian Research Centre in Sex, Health & Society, through HIV Futures Seven, reported that of 1058 participants, 83% where gay men, 16.5% had used ice in the last 12 months (question time frames may explain some of the Ice use differences between the UK & Australia). In HIV futures approximately 15% had a detectable viral load. Although the Kirby Institute, reporting on 2328 people with HIV from the Australian HIV Observational Database estimate 39% of people with HIV have a detectable viral, similar to the UK’s ASTRA study.

So, to reduce HIV what could we do to assist neg and poz guys who use substances with sex. One option is to encourage and prescribe the before pill (Truvada, for Pre Exposure Prophylaxis) to neg guys who use substances like ice during sex. The IPrEx OLE trial found that if neg guys took Truvada at least 4 times a week and preferably daily (as prescribed), then HIV was prevented 100% of the time. Similarly for guys with HIV who use substances with sex, if they begin HIV treatments and successfully maintain an undetectable viral load , then they optimise protection for their partners, especially in the context of an inconsistent condom practice because of substance use. Furthermore we could distribute and promote harm reduction information about how to use drugs more safely and promote gay friendly drug counselling and treatment programs for the small proportion of guys who struggle to manage their substance use and risk harm.

If you’re seeking inspiration search online for Steven Strafford, he is the writer and performer of Methtacular!, which is a musical comedy on addiction. In an interview by Mark S. King he says ” it’s the telling that helps, it’s the talking, it’s the shining light in the darkest places, in the places that no one should ever see or no one will ever love us, and what I’ve found is the opposite, the more you shine light in those places the more opportunities you have for real love”.

Almost all of us use substances in our life time. Substance users are our lovers, our partners, our casual encounters, they are part of our tribes, part of our families part of our communities. Take up the opportunity for real love.

Cipriano Martinez