Undetectable viral load is associated with sexual risk taking in HIV serodiscordant gay couples in Sydney

OBJECTIVE: To determine whether reporting that the HIV-positive partner's viral load is undetectable rather than detectable is associated with unprotected anal intercourse (UAI) in HIV serodiscordant gay couples. METHOD: A cross-sectional study nested within two cohort studies, the Health in Men (HIM) cohort of HIV-negative men, from July 2001 to December 2003 and the Positive Health (PH) cohort of HIV-positive men, from February 2002 to August 2003. The study participants were 119 men in an HIV serodiscordant regular relationship of at least 6 months duration (45 HIV-negative men from HIM, 74 HIV-positive men from PH). The main outcome measure was the occurrence of UAI within the relationship in the previous 6 months. RESULTS: Eighty-two men reported no UAI and 37 reported some UAI. Of couples in which the HIV-positive partner's viral load was reported to be undetectable, 39.4% reported UAI compared with 20.8% of those where viral load was reported to be detectable (P = 0.04). In multivariate analysis, significant predictors of UAI were younger age [odds ratio (OR), 0.94; 95% confidence interval (CI), 0.87-1.00; P = 0.05], greater HIV optimism (OR, 4.98; 95% CI, 1.25-19.8; P = 0.02) and reported undetectable viral load (OR, 2.88; 95% CI, 1.13-7.37; P = 0.03). CONCLUSIONS: Most serodiscordant gay couples do not engage in any UAI. UAI within such relationships is significantly more likely to occur where the HIV-positive partner is reported to have undetectable viral load. UAI in HIV serodiscordant relationships is problematic even if viral load is undetectable because of unknown risk parameters, viral load variability and the possibility of drug-resistant strains of HIV.     

Educating about HIV: prevention, impact mitigation and care

Since very early in the epidemic, education has been identified as central to an effective response. Three different kinds of education can be distinguished: education for HIV prevention, education about treatment, and education to prevent or mitigate the negative effects of the epidemic. This article also considers three different contexts in which education takes place: in schools, at the level of specific groups and across society as a whole. Some 30 years into the epidemic, it is vital that the potential of education is more fully recognized and embraced, not only by agencies and individuals with special expertise in the field (although this is essential), but also by everyone seeking to contribute to the ambitious goals of zero new infections, zero discrimination and zero AIDS-related deaths.     

Understandings of risk among HIV seroconverters in Sydney

This paper examines the risk discourses of Sydney gay men who had recently become HIV positive. 92 in depth interviews were conducted eliciting narratives about the incident in which they believed they became infected. The veracity of this narrative was negotiated between the interviewer and participant. Qualitative analysis was performed in order to distinguish different styles of thinking and acting in relation to risk. Two overarching discourses were distinguished that broadly related to the fields of public health, HIV prevention education, social theory and health policy. These we characterise as ‘quantifiable/objectivist’ and ‘social/subjectivist’. The first approach sees risk as objectively knowable through the application of scientific method or reasoned thinking. The second regards actors as culturally embedded in relation to risk, itself a cultural category. The fact that all men in this study became infected demonstrates the potential fallibility of both approaches. HIV prevention strategies need to take account of both the cultural aspects of risk, understanding the embedded quality of everyday cultural practices such as hygiene, and understand these assumptions are often inadequate for preventing HIV infection. Objectivist approaches also entail problems as many men using them felt HIV infection to be inevitable or unavoidable in some circumstances.     

Willingness to participate in HIV vaccine trials among HIV-negative gay men in Sydney, Australia

This study aimed to determine and describe HIV-negative gay men's willingness to participate in HIV vaccine trials. Data were from participants who completed face-to-face interviews during the first 18 months (to the end of 2002) of recruitment into the Health in Men cohort of HIV-negative gay men in Sydney. A key outcome measure was a scale of Willingness to Participate in HIV Vaccine Trials, with scores ranging from 1 (unwilling) to 4 (willing). The 903 participants ranged in age from 18 to 75 years (median = 36). Mean of Willingness to Participate in HIV Vaccine Trials was 2.53 (standard deviation = 0.54), with approximately 51% of the men having a score greater than the midpoint of 2.50. A reduced linear regression model yielded four significant independent associations with Willingness to Participate in HIV Vaccine Trials: lack of tertiary education (P < 0.001),having engaged 'in the previous six months' in any unprotected anal intercourse with casual or non-concordant regular partners (P < 0.001), higher self-rated likelihood of HIV infection (P < 0.01), and higher mean scores on a scale of Comfort with Participation in HIV Vaccine Trials (P < 0.001). The willingness of HIV-negative gay men at potentially higher risk for HIV to participate in HIV vaccine trials augurs well for enrolment in HIV vaccine efficacy trials. Recruitment into trials is likely to be enhanced by addressing salient concerns such as confidentiality and vaccine-induced antibody positivity. Also, it will be important to ensure that gay men are educated and fully informed about HIV vaccines and trial processes.     

The injection of methadone syrup in New South Wales: patterns of use and increased harm after partial banning of injecting equipment

OBJECTIVE: To describe methadone injectors and the risk practices associated with injecting methadone in New South Wales, Australia. To assess the impact on injecting drug use and risk behaviour of the withdrawal of methadone injecting equipment from government-funded needle and syringe programs. METHOD: Cross-sectional survey, conducted in 1999, of 206 people who had injected methadone at least once in the previous month. Participants were from Central Sydney, West Sydney and rural New South Wales. RESULTS: Of participants who had injected both methadone and other drugs in the previous month (n=162), significantly more reused their methadone injecting equipment compared with those who reused their other drug injecting equipment (60% vs. 28%, p<0.01). There was no significant difference in terms of sharing injecting equipment, with 19% reporting sharing methadone injecting equipment and 14% sharing other drug injecting equipment. However, women were more likely than men to share methadone injecting equipment. Over half of the participants had accessed diverted methadone and a substantial minority reported the use of public spaces for injecting methadone. CONCLUSIONS: Our results suggest that the current policy has led to increased reuse of equipment for injecting methadone. IMPLICATIONS: A range of other possible policy options, such as closer monitoring and dilution of take-home doses, increasing oral doses and implementing trials of injected methadone, may assist to reduce the prevalence of methadone syrup injection and related harms.     

Cancer and Aboriginal people in Australia: A review of the literature

This paper provides a thematic review of the literature on cancer in Aboriginal people in Australia, focusing on experiences in diagnosis, treatment and care as well as addressing sociocultural factors to guide the public health response to poorer treatment outcomes. A search of both medical and social scientific databases for journal articles published between 1995 and 2006 show that cancer incidence and possibly survival and mortality data are likely to be underestimated in Aboriginal people. Aboriginal people are more likely to die from cancer than non-Aboriginal Australians. There are significant differences between the cancer experiences of those living in the city and in rural or remote areas. There is also a relative absence of literature on cancer in Aboriginal men, who are likely to have particular needs during diagnosis, treatment and care. In drawing conclusions from these data, it can be seen that Aboriginal people with cancer have poorer outcomes than non-Aboriginal Australians, and there is a need for further research in the patterns of care and predictors of outcomes in Aboriginal men and women with cancer. Particular attention should be given to the different needs and experiences of Aboriginal people in urban or rural/remote areas. These findings indicate an urgent need to allocate additional resources to the treatment and care of Aboriginal people with cancer, in addition to screening interventions. There is also a continuing need to acknowledge cultural differences in the health beliefs of Aboriginal people and to work in partnership with Aboriginal community controlled health organisations.     

Increase in unprotected anal intercourse with casual partners among Sydney gay men in 1996–98

We examined differences over time in Sydney gay men's unprotected anal intercourse, particularly with a view to investigating any behavioural changes after the recent improvements in anti-retroviral therapies. Trends in unprotected anal intercourse were monitored through the Sydney Gay Community Periodic (cross-sectional) Surveys which were conducted at six-monthly intervals between February 1996 and February 1998. Gay men (n=2,863) were recruited and self-completed a short questionnaire at three gay venues and a sexual health clinic. There was a significant increase in unprotected anal intercourse with casual partners (but not with regular partners), applicable to both HIV positive and HIV negative men. Sexual practice was generally unrelated to ideas about recent advances in viral load testing and combination therapies.     

HIV-related discrimination: a survey of New South Wales general practitioners

Abstract: This study aimed to investigate the correlates of human immunodeficiency virus (HlV)-related discrimination among general practitioners. The survey, conducted in 1993–1994, covered a random sample of 878 general practitioners from six of the 12 New South Wales health areas, augmented by 44 general practitioners from the same areas who were antiretroviral drug prescribers. The response rate was 51 per cent, and the final usable sample was 451. Variables examined were: demographic characteristics, the number of HIV-infected patients, personal contact with people living with HIV or AIDS, personal contact with homosexuals, the degree of anxiety about HIV or AIDS, and the degree of HIV-related discrimination. Discriminatory attitudes among general practitioners decreased as contact with HIV-infected patients (P < 0.001), other people living with HIV or AIDS (P< 0.001), and homosexuals (P < 0.001) increased. Anxiety about HIV or AIDS also decreased as contact increased (P < 0.001). Higher levels of anxiety were strongly associated with higher levels of HIV-related discrimination (P< 0.001). The demographic correlates of discrimination among general practitioners were the same as those found in the wider population. The professional care of people living with HIV and AIDS was concentrated among a small number of general practitioners, many of whom were homosexual. Ten general practitioners were carrying extraordinarily high caseloads of over 200 HIV-infected patients each. Older, heterosexual and male general practitioners are an important target for education campaigns, and the professional care of people living with HIV or AIDS should be encouraged among a wider group of general practitioners.