CANFAR Young Professional Council presents . .  

Speakers Night

Tuesday, February 26th 2013 6.30-9pm,

The 519 Church Street Community Centre, Toronto, Ontario

The CANFAR Young Professional Council’s Education and Outreach Committee is proud to announce its second annual Speakers Night, to be held on the evening of Tuesday, February 26, 2013. The event will feature a diverse panel of speakers directly involved in the HIV and AIDS Community, each of whom will present varying perspectives on the social, legal, medical and emotional issues that impact individuals and communities affected by the virus both within Toronto, and across Canada. The goal of the evening is to raise awareness, support ongoing education related to prevention, transmission, and treatment, and promote community-led discussion about the disease. As such, while the speakers will make formal presentations, a portion of the evening will be open for a panel discussion. We encourage all attendees to come with questions!

The event will be held at The 519 Church Street Community Centre from 6:30pm – 9:00pm.

Light refreshment will be provided. Admission is FREE, and all are welcome.

Guest Speakers:

Leonard

Speaker c/o People With AIDS (P.W.A) Foundation

Dr. Trevor A. Hart

Associate Professor in the Department of Psychology at Ryerson University

Cécile Kazatchkine 

Policy analayst, Canadian HIV and AIDS Legal Network

Dr. Kelly MacDonald

Director of HIV Research Program, Department of Medicine, University of  

This article by Michael Carter first appeared in aidsmap.com here. 

Adding maraviroc and raltegravir to standard HIV treatment regimens achieves rapid suppression of viral load in semen, Canadian investigators report in the online edition of the Journal of Infectious Diseases. Intermittent, low level shedding of HIV in semen was also less likely to occur in people taking intensified therapy than in people treated with a standard three-drug regimen. 

“We found that the incidence of IHS [isolated semen HIV shedding] was significantly reduced in participants taking iART [intensified antiretroviral therapy],” write the authors. “However, one participant demonstrated high level (often > 10,000 HIV RNA copies/ml) IHS that persisted for 14 months after starting treatment. This indicates that occasional HIV sexual transmission might still be possible despite ART with an undetectable blood viral load.”

HIV treatment that suppresses viral load to undetectable levels has been shown to reduce the risk of transmission by up to 96%. There is a growing consensus that antiretroviral therapy has an important role in prevention. However, virus has occasionally been detected in the genital fluids of people who have an undetectable blood viral load, and there have been isolated case reports of transmissions in such cases.

Investigators in Toronto had previously found that the antiretroviral drugs maraviroc (Celsentri) and raltegravir (Isentress) had good penetration into semen. They therefore wanted to see if intensifying standard antiretroviral treatment with the addition of these drugs reduced the frequency of intermittent shedding of virus in semen.

Their study population comprised 13 gay men who started HIV treatment with the intensified regimen and 25 controls who received standard triple-drug therapy. None had a sexually transmitted infection, a known factor associated with shedding of virus in semen.

Paired blood and semen samples were obtained over two years.

People treated with the intensified regimen had a higher nadir (lowest ever) CD4 cell count and lower baseline viral load in blood than the men who were treated with the standard combination (340 vs 213 cells/mm3; p = 0.001; 7000 vs 50,000 copies/ml, p = 0.05). However, baseline viral load in semen was similar (5136 vs 2979 copies/ml).

Viral load in semen fell more rapidly among the men taking intensified therapy, who were significantly more likely than those treated with a standard regimen to have undetectable viral load in semen after two weeks of therapy (12/13 vs 20/26, p = 0.036).

“Individuals initiating an intensified ART regimen were more likely to achieve virologic suppression in semen by two weeks,” comment the investigators.

Isolated shedding of virus in semen was detected in 48% of participants taking standard treatment compared to 15% of men taking the intensified regimen, a significant difference (p = 0.048).

Restricting analysis to men with an undetectable viral load in their blood showed that intensified therapy was associated with a reduced frequency of shedding of virus in semen (7 vs 15%).

High level shedding in semen (viral load above 5000 copies/ml) was observed in 16% of men treated with a three-drug regimen and one participant (8%) whose therapy also included maraviroc and raltegravir.

One man with an undetectable viral load in his blood continued to have detectable viral load in his semen for 14 months after commencing intensified treatment.

This prompted the investigators to see if virus continued to be shed in the semen of men taking long-term HIV therapy.

They examined paired blood and semen samples obtained from 26 additional men who had been taking long-term standard antiretroviral treatment, in some cases for over five years. All had an undetectable viral load in blood and no sexually transmitted infections.

Approximately half the men who had been taking treatment for under six months had virus intermittently detectable in semen; this fell to 20% of men who had been taking therapy for between one and three years; but no man treated for over three years had virus detectable in semen.

“It is encouraging that IHS was not observed after prolonged ART,” write the authors.

The authors believe their results support research showing that effective HIV therapy has a significant impact on the risk of transmission.

Nevertheless, they conclude “it remains clear that IHS, potentially at very high levels, can occur despite effective antiretroviral therapy, even with the addition of agent with enhanced semen penetration…whether the phenomenon of IHS relates to actual transmission is not known.”

Reference

Osborne BJW et al. The impact of antiretroviral therapy duration and intensification on isolated HIV-1 RNA shedding. J Infect Dis, online edition, 2013.

PositiveLite.com adds: detectable viral load in the semen does not necessarily represent a significant risk of HIV transmission, at least at low levels. One needs to understand how much virus in the semen may lead to the possibility of transmission. Canadian researcher Rupert Kaul in the interview referenced below said "There is no validated “threshold level” for semen HIV and transmission, especially since semen virus levels go up and down much more than blood viral levels, but we think that a level over 5,000 RNA copies/ml (in the semen) is most relevant in terms of transmission risk."

We'd also add that readers should exercise caution in assuming that the results reported here in any way reflect on the validity of HPTN 052 data which saw a reduction of the risk of transmission of those on ART treatment (not even necessarily with undetectable viral loads) of 96%. That study group would almost certainly have included particiipants who were experiencing some degree of viral shedding.  In other words, the 96% figure does not need to be adjusted to take in to account the impact of viral shedding.

Many sexual health resources over-simplify this complicated area of research, to make it accessible to consumers. For example one recent resource for gay men said "We know that the amount of HIV in our blood is not necessarily the same as it is in our semen or our ass - some studies suggest that difference may be more common than we realize." It's our view, however, and the above research in fact confirms this, that how much virus is being found in the semen of men with undetectabe viral loads, how likely it is to occur, for how long and whether those levels of seminal virus could conceivably result in the risk of transmission all need to be considered in assessing the usefulness of statements like this.

This article by Gus Cairns first appeared on aidsmap.com here.  

A paper in The Lancet Infectious Diseases by scientists from the UK’s Medical Research Council and the Health Protection Agency (HPA) has calculated that the number of gay men in England and Wales who become infected with HIV each year remained unchanged between 2001 and 2010. This is despite a considerable increase in testing and, they estimate, a 40% reduction in the proportion of gay men with HIV who are undiagnosed.

The paper concludes that, in England and Wales at least, the proportion of gay men with HIV who are on treatment and with undetectable viral loads is currently too low to bring about a decline in annual HIV incidence in this population. This is in contrast to declines in diagnosis, and claims of declines in incidence, seen in places such as San Francisco, the province of British Columbia in Canada, and some locales in South Africa.   

As well as extending HIV testing to non-traditional settings and urging gay men to test more frequently, the authors conclude that “the initiation of treatment on diagnosis, regardless of CD4 count might well be necessary to achieve control of HIV transmission”, and welcome the new BHIVA treatment guidelines' recommendation "that clinicians discuss the benefits of early treatment uptake as a prophylaxis to protect sexual partners” as a step towards this.

Calculating incidence

The paper is a mathematical model. It uses available data on diagnoses, CD4 counts at diagnosis, and the proportion of people on antiretroviral therapy (ART) to make estimates of the true annual number of infections (annual incidence) in gay men, the number undiagnosed, average time gap between infection and diagnosis, the distribution of CD4 counts among diagnosed and undiagnosed men and the proportion who are on treatment and with an undetectable viral load.

Although mathematical models are always estimates, in this case surveillance data from the UK are of good enough quality to make them quite robust, though because by definition fewer very recent infections are diagnosed, incidence estimates for the last two years are less certain than for previous years.

The incidence rate is not the same as the new diagnosis rate in HIV, because of the time lag between infection and diagnosis. If the number or frequency of HIV tests go up, the number of diagnoses will tend to go up, since more long-term undiagnosed infections will be identified. The researchers got round this problem by using CD4 count at diagnosis – available for the majority of diagnosed people in England and Wales – as a surrogate for the time delay between infection and diagnosis, given that CD4 counts in people with untreated HIV tend to decline at an even rate over time.  

Results – diagnosed and undiagnosed

The number of diagnoses in gay men in England and Wales increased from about 1800 in 2001 to 2600 in 2010. However by adjusting this for CD4 count at diagnosis, the researchers estimated that the true annual total of HIV infections in gay men had remained virtually unchanged, from 2200 in 2001 to about 2300 in 2010. There was an increase in incidence to about 2700 a year in 2003-4, due to increased rates of sex without condoms in gay men, but this has reduced since.

This reduction is due, the researchers say, to more gay men taking tests and to a shorter period between HIV infection and diagnosis. The number of HIV tests taken by gay men in sexual health clinics has grown nearly fourfold, from 16,000 in 2001 to 59,300 in 2010. As a result, the estimated time between infection and diagnosis has shrunk from four years to 3.2 years during this time, and the proportion of gay men with HIV who are undiagnosed from 37 to 22%.

The reason it has not shrunk more, say the authors, is due to gay men not testing often enough. Last year, study co-author Valerie Delpech of the HPA told the IAPAC Prevention Summit that only an estimated 10 to 15% of gay men took an HIV test every year, and that two-thirds of gay men who had had a test at a clinic had, two years later, not returned to that clinic for another one.  

Because there are (as of 2010) 3.2 years’ worth of undiagnosed infections in the population, the total number of gay men with HIV who are undiagnosed in England and Wales was estimated as 7690 in 2010. This was only a small increase from 7370 in 2001 and represents a 16% decline from 9140 in 2004-5, again due to more testing.

The proportion of gay men with HIV who are undiagnosed has gone down by 40% while the number has scarcely changed because total HIV prevalence and the number of UK gay men living with HIV has grown over the same period.

Results – implications for treatment

In 2001, at HIV diagnosis, about 65% of gay men had a CD4 count under 500 cells/mm3, 40% under 350 cells/mm3, and 18% under 200 cells/mm3. Ten years later, the proportion in these three categories had only fallen by about 5%. This means that less than 40% of gay men would currently be advised, under treatment guidelines, to begin taking antiretroviral therapy (ART) for treatment reasons as soon as they are diagnosed.

The researchers calculated that, because more undiagnosed infections are recent ones, only 20% of undiagnosed gay men had a CD4 count under 350 cells/mm3 and only 45% under 500 cells/mm3. Further decreasing the proportion of gay men with HIV who are undiagnosed, and raising or abolishing the CD4 threshold for treatment initiation, would therefore have considerable cost implications for the National Health Service in England and Wales.

Conclusions

In many ways, the UK’s response to HIV has been excellent. The proportion of gay men with a CD4 count under 350 cells/mm3 who are on ART has increased from 75% in 2001 to 84% in 2010; 65% of all patients in care, including the untreated, have undetectable viral loads; and annual loss to follow-up of those attending care is under 5%.

In the US, in contrast, it is estimated that there are more gay men who are diagnosed but not taking ART than there are undiagnosed, and that only 28% of people with HIV are virally suppressed. But gay men in other countries test more frequently: as an accompanying editorial by Reuben Granich of UNAIDS points out, the 22% of gay men who remain undiagnosed in the UK is not as good as an estimated 14% in Vancouver and only 6% in San Francisco.

Because most of those with detectable viral loads in the UK are undiagnosed, it is estimated by the HPA that up to 50% of HIV infections in gay men here could be being transmitted by men in primary HIV infection and another 35% by undiagnosed men with long-term infection. The authors conclude that treatment initiation at diagnosis, earlier, more targeted testing, and better primary HIV prevention all need to be part of any national HIV prevention plan for England and Wales.

References

Birrell PJ et al. HIV incidence in men who have sex with men in England and Wales 2001-2010: a nationwide population study. The Lancet Infectious Diseases, early online edition: http://dx.doi.org/10.1016/S1473-3099(12)70341-9. See abstract here. 2013.

Granich R HIV in MSM in England and Wales: back to the drawing board? The Lancet, early online edition: http://dx.doi.org/10.1016/S1473-3099(13)70035-5. See first few lines here. 2013.

Studio 180 Theatre Celebrates 10 Years!

One Night Only Staged Reading of

THE LARAMIE PROJECT

Monday February 25, 2013 at 7:00 PM

Panasonic Theatre, 651 Yonge Street, Toronto

Ten years ago, Studio 180 burst onto the Toronto theatre scene with the Canadian premiere of THE LARAMIE PROJECT, a groundbreaking play in the form of a theatrical docudrama that perfectly defined the kind of theatre the founders of Studio 180 wanted to create: socially relevant, thought-provoking, and committed to community engagement. That was the very beginning of the company that is now considered one of the city’s most vibrant and dynamic.

On Monday February 25, 2013, over 50 artists from Studio 180 productions, past and present, will gather to celebrate Studio 180’s 10th birthday by performing a staged reading of THE LARAMIE PROJECT for one night only at the Panasonic Theatre, the same venue where on the other nights of the week Studio 180 will be performing a revival of its acclaimed and popular production of CLYBOURNE PARK (playing February 12 to March 2).

About THE LARAMIE PROJECT

In an internationally reported event, openly gay University of Wyoming student Matthew Shepard was kidnapped, beaten and left to die, tied to a fence on the outskirts of Laramie, Wyoming, in October 1998. Five weeks later, Moisés Kaufman and fellow members of the Tectonic Theater Project went to Laramie, and over the course of the next year conducted more than 200 interviews with people of the town. From these interviews they wrote THE LARAMIE PROJECT, a chronicle of the life of the town of Laramie in the year after the murder.

The play premiered in New York in 2000, playing to rave reviews and impassioned audiences. Time Magazine called it “one of the ten best plays of the year” and it has since become one of the most performed plays in North America.  Studio 180 was honoured to present its Canadian professional premiere in 2003, and is now thrilled to be performing the show again 10 years later.

2003 Production

THE LARAMIE PROJECT

BY MOISÉS KAUFMAN  & MEMBERS OF THE TECTONIC THEATER PROJECT

Directed by Joel Greenberg & Mark McGrinder

FEATURING:  Dorothy Atabong • Daniel Bennett • Richard Binsley • Mark Crawford • Paul Dunn • Audrey Dwyer • Paul Essiembre • Neil Foster • David Fox • Kesta Graham • Jessica Greenberg • Deborah Grover • Martin Happer • Sarite Harris • Daren A. Herbert • Marvin Hinz • Shari Hollett • Ryan Hollyman • Jeff Irving • Sam Kalilieh • Ryan Kelly • Andrew Kushnir • Alison Lawrence • Anthony Lemke • Jeff Lillico • George Masswohl • Mark McGrinder • Tracy Michailidis • Jason Mitchell • Karim Morgan • Sarah Orenstein • Kimwun Perehinec • Alex Poch-Goldin • Kimberly Purtell • Maria Ricossa • Dylan Roberts • Paige Robson-Cramer • Jordy Rolfe • Michael Rubenfeld • Amy Rutherford • Jonathan Seinen • André Sills • David Storch • Michael Therriault • Jennifer Villaverde • Nigel Shawn Williams • Jonathan Wilson

What Toronto critics had to say about Studio 180’s productions of THE LARAMIE PROJECT

“A wonderful tapestry of compassion and hate woven together with invisible threads of homophobia and humanity… An excellent, moving piece of theatre.”

NNNN NOW MAGAZINE

“This play never judges anybody… [Its] straightforwardness, the inevitable snatches of comedy that arise from the interviews and the great swathes of sorrow also apparent in Laramie make the project utterly compelling.”

★★★★ GLOBE AND MAIL

“The play grips, and it won’t let you go”  NATIONAL POST

One Night Only! - Monday February 25, 2013 at 7:00 PM. Â Party to follow!

Panasonic Theatre, 651 Yonge St., Toronto

All tickets $25 416-872-1212 or 1-800-461-333 or here 

Want to see who the other nine are? Go here 

This article fIrst appeared on aidsmap.com here. 

A study from Amsterdam found that gay men who had used post-exposure prophylaxis (PEP) in the past were four times more likely than non-users to subsequently become infected with HIV.

PEP failure does not appear to be the cause of their HIV infection, but rather ongoing risk behaviour following a course of PEP. Self-reported adherence to the PEP regimen was high, at 94%.

The investigators compared HIV infection rates between 2000 and 2009 in 355 men, who had in total received 385 courses of PEP, with infection rates over the same period in 782 gay men entering the Amsterdam Cohort Study. They measured HIV incidence three and six months after receiving PEP in the former group and after cohort entry in the latter.

HIV incidence, translated into infections per man per year, was 6.4% in men who had taken PEP and 1.6% in the cohort study. Three out of the eleven PEP users who acquired HIV were positive three months after PEP but the other eight were only found to be positive six months later, indicating that few - if any - infections were acquired while actually taking PEP.

“Our study showed a high incidence of HIV among MSM [men who have sex with men] who used PEP, an indication of ongoing risk behaviour,” write the investigators. “This implies that PEP alone for this group is not sufficient to prevent HIV infection, and a combination of other more comprehensive preventative strategies is needed.”

Comment: It is important not to interpret this study as a failure of PEP. Instead, it indicates that gay men who come forward for PEP rightly see themselves as being at high risk of HIV, but find that PEP is not a strategy they can use often enough for it to be protective. Previous studies of PEP have also found that, while it has an efficacy of about 80% for individual infections, its use makes no difference to infection rates on a population level. The high HIV incidence in PEP seekers suggests that they might be ideal candidates to be offered an ongoing course of PrEP (pre-exposure prophylaxis). At present, PrEP is still regarded as an experimental prevention technique and access to it is limited to unlicensed or clinical trial-based use.