Pam Harrison

July 22, 2014

MELBOURNE, Australia — Five marginalized groups are disproportionately driving the global HIV epidemic, the World Health Organization (WHO) reports, and addresses them in new guidelines.

Men who have sex with men, sex workers, injection drug users, transgender individuals, and people in prisons are among the groups targeted for prevention and treatment.

HIV rates are "going down all over the world, with the exception of key affected populations," Fabio Mesquita, MD, director of the HIV and viral hepatitis program at the Ministry of Health in Sao Paulo, Brazil, explained during a news conference here at the 20th International AIDS Conference.

"If we don't address key affected populations, we won't reach our goal of controlling the epidemic by the year 2030," he said.

Recent statistics indicate that men who have sex with men are up to 19 times more likely than people in the general population to be infected with HIV, female sex workers are up to 14 times more likely to be infected, and transgender women are almost 50 times more likely to be infected.

"In all parts of the world, these populations have compromised access to good services," said Gottfried Hirnschall, MD, director of the WHO Department of HIV/AIDS.

 
There is strong evidence for this recommendation.
 

The risk behaviors and vulnerabilities of people in these target populations result in them not being able to access the HIV-related services generally available to others.

In addition, laws that stigmatize people and penalize sexual orientation drive risky behavior underground, making it difficult, if not impossible, for people at high risk for HIV to access HIV prevention and care services, speakers at the news conference explained.

As a consequence of this hostile environment, rates of new HIV infections are increasing in all these groups, but especially in men who have sex with men, a group in which "explosive epidemics" of HIV are occurring in many parts of the world, Dr. Hirnschall reported.

It is estimated that up to 50% of all new HIV infections occur in these groups, according to the Joint United Nations Programme on HIV/AIDS.

One of the major recommendations in the guidelines is that pre-exposure prophylaxis, or PrEP, be part of a comprehensive HIV prevention package for men who have sex with men.

"There is strong evidence for this recommendation," said guideline chair Chris Beyrer, MD, who is director of the John Hopkins Centers for Public Health and Human Rights in Baltimore, Maryland, and president-elect of the International Aids Society.

However, Dr. Beyrer stressed that treatment is not recommended for all men who have sex with men, only those who want it and who are at risk for HIV. He explained that PrEP must be considered along with other known HIV prevention strategies, such as condoms, condom-appropriate lubricant, and education.

The other major recommendation is to make naloxone, an opioid antagonist, available in the community for the prevention of overdose. People likely to witness an opioid overdose should have access to naloxone and be instructed in its use for the emergency management of suspected opioid overdose, according to the guidelines.

Overdose Deaths

"We know that, worldwide, 69,000 individuals die from heroin or opioid overdose each year," said Phillip Read, MD, medical unit manager at the Kirketon Road Centre in Sydney, Australia. "In fact, HIV-positive people who inject and who are on treatment have a greater risk of dying from an overdose than from HIV." And approximately 60% of overdose deaths occur in the presence of someone else.

Naloxone rapidly reverses the toxic effects of heroin and some opioids, such as oxycodone. For other potent opioids, such as buprenorphine and fentanyl, reversal of overdose is more difficult. The agent can be administered intramuscularly or subcutaneously, or can be aerosolized and sprayed directly into the nostrils.

In a pilot project of opioid-dependent clients, Australian investigators found that almost all people in their study cohort had witnessed an overdose, and almost two-thirds had overdosed themselves. There is a "real opportunity" to intervene, he said.

When the Australian group supplied naloxone to study participants, about 20% used it to reverse an overdose within a year, Dr. Read told Medscape Medical News.

The recommendation from previous guidelines that people who inject drugs have access to sterile injecting equipment through needle and syringe programs remains.

"The importance of these programs in blood-borne virus prevention in people who inject cannot be overstated," Dr. Read said. In Australia, a comprehensive needle and syringe program has been in place since the late 1980s.

As a result, the prevalence of HIV in heterosexual people who inject drugs is below 1%. In fact, in 2012, the primary route of HIV transmission was injection drug use in only 21 cases in the entire country.

It has been estimated that, since its inception, the needle and syringe program has prevented more than 50,000 new cases of HIV in Australia, and more than 100,000 cases of hepatitis C.

"We know that for every dollar spent on needle and syringe programs, over $4 is returned to the state in direct cost savings," Dr. Read reported. "These programs are not only ethically and medically important, they are economically important as well."

The guidelines also recommend that all people from the key populations who are dependent on opioids continue to have access to opioid substitution therapy.

"I think these new guidelines represent an important advance both in public health and human rights," Dr. Beyrer concluded.

The use of PrEP in HIV-negative people at high risk for infection was first addressed in the 2012 WHO guidelines.

The recommendation to consider PrEP an option for HIV prevention in men who have sex with men is both "valuable and important," said Robert Grant, MD, MPH, from the Gladstone Institutes at the University of California, San Francisco. Dr. Grant was protocol chair of iPrEX, a study that showed that PrEP provides a high degree of protection against HIV infection, even without perfect adherence.

"I think the WHO recommendation reflects the high-quality evidence that PrEP provides protection for men who have sex with men," Dr. Grant told Medscape Medical News.

However, he cautioned that people do go through "seasons of risk" and might stop treatment when they no longer feel they need PrEP for HIV protection.

In the IPrEx OLE trial, the first PrEP demonstration project to report outcomes, some people did become infected with HIV after they stopped PrEP, "so we need to work to identify ways to better inform people how they should stop PrEP," Dr. Grant explained.

Dr. Mesquita, Dr. Hirnschall, Dr. Beyrer, Dr. Read, and Dr. Grant have disclosed no relevant financial relationships.

20th International AIDS Conference: Presented July 21, 2014.

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