Newly updated US treatment guidelines are recommending antiretroviral treatment for all people with HIV infection, rather than starting at a particular CD4 range. But for those about to start treatment and their doctors, it’s not quite that simple; the strength of the recommendations varies by category of patient. Here is how a simplified scale looks:

• CD4 count less than 350 – strong recommendation
• CD4 count 350 to 500 - strong recommendation
• CD4 count over 500 – moderate recommendation

Regardless of CD4 count, initiation of ART is strongly recommended for individuals with the following conditions: pregnancy, a history that includes an AIDS-defining illness, HIV-related kidney disease and HIV/hepatitis B virus (HBV) co-infection. The guidelines also include an early treatment recommendation for anyone at risk of transmitting HIV to partners.

You can read a summary of the recommendations, including changes to existing guidelines, here or read the  full guidelines here.  

In contrast, recently issued draft British HIV Association treatment guidelines continue to recommend treatment when the CD4 cell count falls below 350, although treatment may be started earlier in people with hepatitis B or by people concerned about the risk of transmitting HIV to partners.

Canada has no national guidelines at present, a reflection of our provincially administered healthcare system, but our practice tends to follow the US guidelines.   BC and Quebec have their own guidelines.  But it’s likely that these new US guidelines will be influential in affecting treatment decisions here and around the world.

In Ontario, the advice you will receive currently depends, at least to some extent, on who is your doctor.  Some (many?) doctors are now suggesting treatment immediately on diagnosis, with the consent of the patient, of course. Others are suggesting holding off.  But clearly there has been a move towards earlier treatment for some time, driven in part by the evidence of better clinical outcomes   for those who start earlier, and in part perhaps by concerns about the perceived need to curb secondary infections that the treatment as prevention advocates frequently cite.  More on that later.

The issue of when to start treatment has been controversial. Previously, for instance, the panel that decided on the US guidelines was divided.

There has been little reaction to the new US guidelines from the Canadian HIV community to date.  But HIVers from Australia, in the form of NAPWA (National Association of People Living with HIV/AIDS) were quick to state their position.  In a March 28 statement, NAPWA president Robert Mitchell said “It is increasingly clear that untreated infection is bad for the health of people living with HIV, whether their infection is recent or long-term. We also think that people with HIV will value the added benefit of being on treatment in helping reduce the risk of transmitting HIV to others, when used with other proven prevention measures like correct and consistent condom use.”

This two-pronged rationale for earlier treatment contains elements which have been troublesome for people living with HIV in the past.  Over the years, there have for instance been issues raised about the potential side effects from long(er) term exposure to HIV drugs - longer term at least than if treatment were delayed.  Informed consent has also been an issue for some HIVers – nobody wants to be persuaded to start treatment when they are not ready for making that decision. But on this latter point the new guidelines are clear; “patients (who start) ART should be willing and able to commit to treatment and should understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy on the basis of clinical and/or psychosocial factors.”

The longer-term exposure to side effects concerns?  I raised this issue with Dr Julio Montaner, a long-time early-treatment proponent, when I interviewed him for PositiveLite.com earlier this year.  Here’s what he had to say about that. “There is no doubt that antiretroviral therapies have improved dramatically. They are simpler, safer and better tolerated. No doubt about it.  Are they perfect? No they are not….However, if we are having a discussion here on whether starting treatment immediately or on a deferred basis, the gap between those two decisions is somewhere in the order of months to a couple of years. It varies from person to person but when we’ve done studies, the rate of CD4 decline in an untreated person is somewhere between 60 and 120 cells per year. If somebody today says ‘no, I’m going to wait,’ what I say is ‘sure, you can defer antiretroviral therapy, no problem, we are not forcing anybody to start treatment.’ What we are saying is let’s have a discussion."

For an expert narrative on the new US guidelines, I interviewed CATIE’s Sean Hosein last week.  He’s an acknowledged expert on treatment issues and I wanted to gauge his feelings on the impact of the new guidelines for Canada.

Sean cautions against interpreting the guidelines as saying that once people are diagnosed they should start treatment then and there. “What this means” he says ”is that there is an opportunity for doctors and people living with HIV to start the discussion about therapy. Given the therapy that we have today, people are going to be taking it every day for the rest of their lives,  and so people have to be prepared for this – ready, willing and able.”

Do the new treatment guidelines represent a major change? Sean thinks so. ”It’s a major change compared to ten years ago, even five years ago, when they were saying ‘let’s wait ‘til the CD4 counts fall’. But what’s happened is that they’re finding that HIV just doesn’t affect CD4 counts. It causes inflammation inside the body that affects major organs like the brain, the heart, the lungs, the kidneys, the liver, the bones  - and so that’s why there is a push to start treatment earlier.”

I asked Sean to what extent the treatment as prevention arguments – which revolve around, in part, reducing the possibility of secondary infections by suppressing viral load to undetectable levels – might have had on the US decision to recommend starting  treatment earlier.  “I think it’s a mix of two things”, says Sean of the new guidelines. “It’s a mix of trying to do the right thing for the individual person living with HIV and also trying to do something for the rest of society in order to reduce the risk of transmissions.” But  of treatment as prevention, Sean cites the cautions in the guidelines about interpreting HPTN 052 results (the much-publicized study released last year which saw a 96% reduction in the risk of HIV transmission in heterosexual sero-discordant couples) too broadly, noting in particular the lack of data relating to MSM (men whoi have sex with men) , an issue discussed in my interview with CATIE’s James Wilton that you can read here.

On the side effects issue, Sean says the environment has changed. ”That argument, I think was important in the 1990’s and maybe ten years ago when the drugs that were used were much less tolerable.  With the drugs that are commonly prescribed today, the regimes are simpler.  There are side effects but they are generally mild and they tend to go away.  It’s true that people haven’t been on the latest drugs for fifty years so in theory there may be problems in years to come. . . . We need long-term studies to monitor people and those studies are underway.”

I asked Sean if the new guidelines are big news for the HIV community.  Sean thinks so. “It’s about strengthening doctor/patient relationships. I would encourage people who have recently been tested to see this as an opportunity to speak to their doctor about starting treatment early.”

Does he think the US guidelines will shift the Canadian response to HIV infection?  Says Sean “I think it will, because it’s good for people living with HIV. It will keep them alive longer.  It’s a good thing.”

I think so too.  Starting treatment earlier is likely a good thing for many people.  Whether the new US guidelines are driven by a desire for better clinical outcomes for people living with HIV or reflect treatment as prevention policies, or both, is almost immaterial.  I say almost because many of us have been vocal about our concerns surrounding treatment as prevention and we are cautious when some of its key tenets appear to go main-stream. But things have changed. Our knowledge of disease progression has changed. Treatments have changed. My own opinions have changed. So yes, I’m with the US on this one.

Let’s hope that Canada follows suit. 

There is no doubt that our culture – I’m talking gay men here -  has a bit of an obsession with buff bodies. Gyms have never been busier. Clothes are tighter. Porn (or at least gay porn) and gay magazine covers ONLY feature the perfectly muscled.

How does that leave those of us with less than perfect bodies?  Like me. Is there an impact on my psyche, my sense of well-being, even on my risk behaviour? And just how healthy is being obsessed with being healthy anyway? Is there a down-side?

In this PositiveLite.com interview, David Brennan looks at both sides of the coin and draws on his research in to body image, eating attitudes and behaviour among  queer men, particularly examining these issues for racialized queer men in Toronto.  I think you’ll enjoy what he has to say.

Video services courtesy of Guy McLoughlin.

Sometimes we worry here on PositiveLite.com that we are a bit gay-centric.  Our founder, publisher and editor are all gay men, and while we have three active women writers, we have far more male ones. But that’s not to say that, first, we don’t have a huge curiosity about women and HIV and secondly we aren’t committed to writing about women’s issues.  So when Publisher John McCullagh and myself travelled to Oshawa  recently to attend the 2012 Durham Regional HIV/AIDS Conference we decided to take the opportunity to focus on women’s issues that were a prominent part of the program.

According to OCHART – View From The Front  Lines 2011  (which takes the pulse of HIV work in Ontario each year) there were 1,018 new HIV diagnoses in 2010 in our province. Of those, more than 50% were in gay men and other men who have sex with men, 20% were in members of the African, Caribbean and Black communities, and 6% were in people who reported using injection drugs. Women account for about 1 in 5 new diagnoses although the number of new diagnoses in women has declined by over one-third since its high in 2006.

The mean age of women who are newly infected is 35, not too different from the mean age for males.

Community-based HIV/AIDS programs appear to be reaching at-risk women: agencies estimate that between 25 and 28% of clients using education, outreach and support services are heterosexual women, which reflects the epidemiology.

That's what the data says. The same report is instructive about where new infections are occurring and clearly all the action isn't in the big cities. Says OCHART  “Although Toronto still has the largest number of new diagnoses each year, that number has been dropping steadily for the past five years – while the number of new diagnoses per year has been increasing in other parts of the province. In the last year alone, there was an increase in new diagnoses in South West (10%), Central East (10%), and Ottawa and Eastern (24%). Each of those parts of the province had its largest number of diagnoses in a single year in 2010.”

So Durham is at the epicentre of this trend of increasing new infections away from the larger urban centres.  It’s regional agency, the very progressive AIDS Committee of Durham  Region, is located in downtown Oshawa, somewhat of a bedroom community to Toronto, although home to a major GM factory important to local employment.   Oshawa has a sprawling population of about 152,000; it’s about 60 kilometers east of Toronto. 

Areas such as Durham have their own contributing factors to new infection rates. The proximity of a sexual playground like Toronto is one, of course.  But so are things like the lack of a centralized LGBTQ community and related establishments, homophobia, fewer resources for the at risk and infected and the phenomenon of the married MSM (men who have sex with men.) Women are even more isolated here than they are in large urban centres, seldom considered at risk, with HIV testing not on many health care professionals' radar.

Armed with this background, publisher John McCullagh talked to Claudia Medina (whom I have known since she was a baby, LOL). Claudia is the Women's Prison Program Co-ordinator, Prisoners with HIV/AIDS Support Program (PASAN).  Claudia talks about the particular problems that women with HIV face who are incarcerated in the Canadian correctional system.

Two years ago today, I was diagnosed with HIV. Having managed to remain negative throughout the first 28 years of the epidemic, here was I, in my sixties, suddenly finding myself HIV-positive. The diagnosis itself was not unexpected - I had made some decisions to have unprotected sex - but the shame of having to admit that I had seroconverted was difficult for me to reconcile with the self image I had of myself. And with the image others had of me. After all, here I was - an educated, aware gay guy who’d lived through the early years of AIDS, a social worker who’d worked within the gay community for over thirty  years - now having to deal with the shame that I’d allowed myself to become poz.

But I was well-connected in the community and had the support of a wonderful life partner and some great friends. They, along with the excellent care I was receiving from my GP, who is also an HIV primary care physician, enabled me to handle my emotional turmoil. And because I have a natural curiosity, and because I wanted to learn as much as possible about HIV and what it meant to live with it, I began to read voraciously about every aspect of it. I found a great deal of help and useful information at a number of websites, particularly Canada’s CATIE,  Vancouver’s Health Initiative for Men  and the UK’s aidsmap.com. 

Then I found PositiveLite.com. This website was a revelation - a Canadian online HIV magazine by and for people who are either HIV-positive or who are our friends and supporters. Here were women and men, both from Canada and elsewhere, who were writing openly about their lives as poz people. And they were writing not just about living with HIV but about all aspects of their lives, which were as rich and as varied as those who were not living with this chronic illness.

But there was more. They were also writing, from their own lived experience as HIVers, about issues of importance to us all - the best approach to take in the 21st century in preventing the spread of HIV, developments in treatment, about stigma and discrimination, about how to manage disclosure and deal with the increasing criminalization of non-disclosure, about aging with HIV and about how, paradoxically, HIV had changed their lives for the better.

I was so impressed with what I read on PositiveLite.com that last summer I wrote to publisher Brian Finch to tell him so. He was very gracious in his response and asked if I would be interested in providing more specific feedback about the website, which was about to undergo a major redesign. I said I would. Before I knew it, I had an email from PositiveLite.com editor Bob Leahy inviting me to write for the magazine the story of my seroconversion.  I agreed to do so, anonymously. I was not quite ready, at that stage, to have my name, face and the intimate details of my life plastered all over the internet for all to see.

I guess Brian and Bob must have liked what I wrote, because they arranged for my story to be picked up by aidsmap.com. So it was not long before Bob started using his considerable charm in encouraging me to become a regular contributor and to write more about what I was learning. I took some time to say yes, because I’d just retired from my long-time job and was looking for volunteer opportunities that would provide me with the chance to to work with people face-to-face and to make new friends - writing, after all, is a somewhat solitary pursuit. But, in the face of Bob’s persistence, I overcame my hesitance.

So before I knew it, I was actually starting to enjoy sharing my experiences as an HIVer and my increasing knowledge of HIV with PositiveLite.com’s community of readers. Through doing so, I quickly decided that I no longer wanted to remain anonymous. I was ready to stand tall and proud as an openly HIV-positive gay man. For this I have to thank Brian and Bob and the opportunities they provided me to share my thoughts and experiences with others. After all, coming out as a gay guy when I was in my early twenties had been a liberating experience and I reckoned that coming out as poz should be equally as liberating. And so it has proven to be. I now feel a great sense of freedom and liberation living as an openly poz guy.

It was not long before I began to attend HIV community events and do interviews for PositiveLite.com with other people who who had interesting things to say. Then, at the beginning of this year, Bob offered me the position of assistant editor. And now, just three months later, I find myself as publisher. Never in my wildest dreams did I think, on March 15, 2010, the day I received my HIV diagnosis, how having HIV would change my life in a such a positive (pun intended!) way within two short years. 

As he wrote here yesterday, Brian has come to the decision that it’s time for him to pursue some new opportunities and that he’d fulfilled his job of creating PositiveLite.com. Last week, he asked me if I’d consider taking over the position of publisher. How could I say no? I’m in awe of Brian and what he’s created here. He’s a guy who’s lived proudly and openly with HIV for over half his life. He’s a true survivor with a passion for enabling HIVers who may not otherwise feel they have a voice to have the opportunity to be involved in a discussion about what it really means to be HIV-positive today - the rationale behind PositiveLite.com.

I’m both honoured and humbled that Brian has entrusted his creation to me. His are enormous footsteps to tread in, yet I fully intend to ensure that his trust in me is justified.   I can do that only because Brian will be remaining an integral part of PositiveLite.com as our founder and I will continue to benefit from his wisdom and wise counsel. I’m also supported by our knowledgeable and indefatigable editor, Bob Leahy, and by an amazing community of writers and contributors, who are at the heart of PositiveLite.com. Without them, the magazine would not exist.

I have a strong sense that this three-year-old, PositiveLite.com, is poised to continue its progress beyond its early years as it becomes an increasingly important and respected part of Canada’s HIV community. And while we are indeed Canadian, and will continue to reflect the Canadian experience, we remain open to the world - indeed half our readers and many of our writers now come from outside our nation’s borders. We welcome that diversity of experience. Yet we are equally committed to reflect the increasingly diverse face of HIV, both in Canada and elsewhere.

At present, most - but by no means all - of our writers are gay men who write about HIV and their lives from that perspective. This reflects the historical nature of HIV in countries like ours. Gay men still account for the majority of HIVers in Canada, and their experience of HIV will continue to be portrayed in our pages. But the face of HIV is changing, a reality that all of us here at PositiveLite.com are committed to reflecting. Thus, we’re actively engaged in increasing our coverage of HIV as it affects women, First Nations, transpeople, those from countries where HIV is endemic, injection drug users and others. By the same token, by the middle years of this decade it’s estimated that 50% of all HIVers in North America will be aged 50 or older. This reflects the reality that, thanks to anti-viral medications, HIVers are living longer than anyone ever expected only 15 years ago. There are also an increasing number of people who, like me, are seroconverting in later life. These realities will continue to be reflected in our pages even as we continue to tell the stories of younger people infected with and affected by HIV.

We will always remain faithful to our mandate, to be a place for HIVers and our allies to talk about the reality of our lives. Sometimes we will be funny, sometimes angry, sometimes controversial, but always honest.

As I said earlier, you, our readers and writers, are at the heart of what we are all about here at PositiveLite.com. I hope you continue to enjoy, be inspired by and encouraged by what you read here. And if you think you have something to say yourself, then why not consider writing about it here on PositiveLite.com. It may be that you just want to comment on something you’ve read here, in which case I invite you to share it in the comments section at the end of each article (currently an underutilized resource). Or it may be that you want to contribute your own thoughts through submitting a post of your own. In that case, I invite you to contact us through our facebook page, via email to our editor Bob Leahy at This email address is being protected from spambots. You need JavaScript enabled to view it. or by sending me a tweet @John_McCullagh. 

Thank you all for your support. And Happy Reading!

Libby Davies, MP for Vancouver East talks Housing and HIV with PositiveLite.com editor Bob Leahy. Libby discusses the need for a Canadian Housing Strategy that would include populations with HIV/AIDS, based on the premise that housing is a human right. The video was filmed at the North American Housing and HIV Research Summit in New Orleans in November 2011, as part of a collaboration between the Ontario HIV Treatment Network (OHTN) and PositiveLite.com

The year 2011, just ended, marked the thirtieth anniversary of the HIV/AIDS pandemic. Much has been achieved in those three decades, most notably advances in treatment that have changed the face of HIV for those who have access to antiretroviral (ARV) medication from a terminal illness to a chronic yet manageable disease.

But of late there’s been other good news to celebrate. Just last month, for example, researchers from the University of Western Ontario announced that clinical trials are about to begin on a new HIV vaccine they’ve developed. And it does seem that, increasingly, more and more experts are becoming convinced that appropriately treated HIVers with an undetectable viral load are much less likely to pass on the virus than people not on treatment. However, as PositiveLite editor Bob Leahy recently pointed out by how much and in what circumstances is still subject to debate.

The latest people to take the view that HIVers on treatment with undetectable viral loads are unlikely to infect their sexual partners are the two organizations that write the HIV treatment guidelines for the UK, the British Association for Sexual Health and HIV  and the British HIV Association. They’ve done this via their newly revised guidelines for the use of post-exposure prophylaxis (PEP).

PEP is an emergency measure aimed at preventing HIV infection after the possible exposure of an HIV negative person to the virus. The new UK guidelines are notable for no longer recommending that PEP be provided in a number of situations where the “source partner” is known to be HIV+ and to have an undetectable viral load. These situations include unprotected vaginal intercourse, unprotected insertive anal intercourse and oral sex. But PEP is still recommended following unprotected receptive anal intercourse.

The guidelines are also notable for not recommending PEP in any situation in which the source partner is thought not to belong to a social group in which HIV prevalence is high, such as gay men or people from high-prevalence countries (such as those in sub-Saharan Africa). The guidelines also clarify that, due to the very low risk of infection, PEP is unnecessary following human bites or contact with a discarded needle.

 (Unlike the UK and many other countries in the developed world, Canada has no national guidelines for the use of PEP for non-workplace exposure - such as unprotected sex, a condom breaking during sex, needle sharing or sexual assault -  although some provincial guidelines exist. As a result, PEP for non-workplace exposure is rarely promoted in Canada. On the other hand, PEP after workplace exposures - for example a health care worker who accidentally suffers a needle-stick injury - remains the “standard of care” and is widely used in this country.)

Yet, despite the growing body of evidence that having an undetectable viral load significantly reduces the likelihood of an infected person passing on the virus to an uninfected sexual partner, Canada has witnessed an escalation in the number of people prosecuted for allegedly exposing partners to HIV even if they had an undetectable viral load and/or were using protection such as condoms or engaging in a low risk activity such as oral sex. Ontario is home to the majority of HIV-related prosecutions in Canada and is also one of the leading jurisdictions in the world when it comes to such prosecutions.

Part of the problem is that the law around HIV disclosure has never been legally defined. Rather, it comes from a 1998 decision of the Supreme Court that HIV+ people have a legal duty to tell a sex partner that they have HIV before they have sex if there’s a “significant risk” that they’ll pass on the virus to that person. This lack of clarity on what constitutes significant risk has meant that the police, Crown attorneys and lower courts have been inconsistent in how they interpret what sex acts, and under what circumstances, pose a significant risk of HIV transmission.

In last month’s Canadian Medical Association Journal, Julio Montaner, one of Canada’s and the world’s leading HIV medical doctors, along with colleagues from the British Columbia Centre for Excellence in HIV/AIDS called for the end of prosecutions for allegedly exposing sexual partners to the virus. “To put the burden on the person infected with HIV that they have to disclose when they may be on treatment or using a condom, or doing both, is really not appropriate,” Montaner told The Vancouver Sun. “Let me be clear, I think that people who behave irresponsibly, they need to be judged accordingly and there are laws to address those issues...but to have a policy that selectively targets HIV is discriminatory and discourages people from seeking out testing and treatment.”

All this will be coming under intense scrutiny next month, when the Supreme Court of Canada is to hear two appeals involving HIV non-disclosure. In both cases, one from Manitoba, the other from Québec, the accused are HIV+ and had consentual sex with their partners without disclosing their HIV status although they used condoms or were on ARV medication that kept the risk of transmission very low. In each case, the accused were acquitted by the provincial Courts of Appeal. However, prosecutors in both cases applied for an appeal before the Supreme Court.

So it was of particular concern that in September 2011, Ontario’s Attorney General indicated his government’s intention to file an application to intervene in the Supreme Court hearing. The government’s intent was to call on the Court to rule that people living with HIV must disclose their status before any sexual activity whatsoever - even in the case where there’s a negligible, effectively zero, risk of HIV transmission - and that not disclosing should be prosecuted as an aggravated sexual assault, which is one of the most serious offences in the Criminal Code.

It was especially troubling that the Ontario Attorney General's office took this position at the same time that it was engaged in ongoing discussions regarding the development of prosecutorial guidelines for allegations of HIV non-disclosure.

So it was good news to learn that, just before Christmas 2011, Ontario quietly withdrew its application to intervene before the Supreme Court. The government hasn’t released its reasons for this about-face, although it must be said that the governing Liberal party has just recently been returned to power following a provincial election where they gained a plurality of seats in the provincial parliament. The premier also appointed a new Attorney General who may have been instrumental in deciding against his predecessor’s decision to intervene.

However, the appeal before the Supreme Court will still be going ahead - it starts on February 8, 2012 - at which time the Court will be asked to define “significant risk”. Hopefully, in reaching a decision on the two cases before it, the bench will take into account current medical and scientific research about the risk of transmission and make a decision that’s compatible with scientific, medical, public health and community efforts to prevent the spread of HIV and to provide care, treatment and support for people living with HIV.

You can listen to an excellent debate about the current law - and recommended changes to it - in a podcast of the CBC Radio current affairs program The Current that was broadcast on December 21, 2011. In it Anna Maria Tremonti talks with Tim McCaskell, a long-time AIDS activist and person living with HIV, and Carissima Mathen, an associate professor of law at the University of Ottawa.

Sources:

Peabody, R.: PEP guidelines for the UK revised to take account of undetectable viral load. London: NAMaidsmap (December 2011): http://www.aidsmap.com/PEP-guidelines-for-the-UK-revised-to-take-account-of-undetectable-viral-load/page/2186929/ Accessed December 29, 2011

Wilton J.: Post-exposure prophylaxis fact sheet. Toronto: CATIE (2011) http://www.catie.ca/fact-sheets/prevention/post-exposure-prophylaxis-pep Accessed December 29, 2011

Wilton, J.: Enhancing the potential benefit of PEP. Toronto: CATIE (June 2011) http://www.catie.ca/en/catienews/2011-06-23/enhancing-potential-benefit-pep Accessed December 29, 2011

HALCO News Fall 2011. Toronto: HIV & AIDS Legal Clinic Ontario http://www.halco.org/wp-content/uploads/2011/11/HALCO_Newsletter_Fall_2011.pdf Accessed December 29, 2011

Salerno, R.: Ontario withdraws intervention in HIV criminalization cases. Toronto: Xtra! (December 2011) http://www.xtra.ca/public/National/Ontario_withdraws_intervention_in_HIV_criminalization_cases-11273.aspx Accessed December 29, 2011