With PrEP, Daily Dosing May Not Be Necessary

One study, known as the Alternative Dosing to Augment PrEP Pill Taking (ADAPT) study, found that individuals who are given appropriate support can have excellent results with non-daily PrEP dosing schedules. The ADAPT study, conducted by researchers in the United States and Thailand between 2012 and 2014, involved 357 men—both cisgender and transgender—who have sex with men. Half were enrolled through a community clinic and clinical research site in Bangkok and the other half were enrolled through a clinical research site in Harlem, a traditionally African American enclave in upper Manhattan. The men were randomly assigned to take either 1 PrEP tablet daily, 1 tablet twice a week along with a post-sex dose, or 1 tablet before and 1 after sex.

The researchers followed up with the participants via self-reports, electronic drug monitoring devices that recorded pill bottles being opened, and dried blood samples or peripheral blood mononuclear cells that revealed whether there were adequate concentrations of the PrEP medications in participants’ systems. In-person clinic visits took place weekly in the early stages and tapered off to roughly once a month for the duration of the trial. The goal was to ensure that study subjects had sufficient coverage for all instances of sexual intercourse via their ingestion of PrEP.

By offering non-daily PrEP regimens, providers can acknowledge that an individual’s sex life may change over time, Robert M Grant, MD, MPH, a professor at the University of California, San Francisco School of Medicine and the lead author of the study, told Contagion®. “People move into and out of seasons of HIV exposure, depending on their relationship status, their substance use, their housing, their employment and so much else,” he said. A non-daily PrEP regimen allows users to easily start and stop the medication depending on their needs.

However, the results of the ADAPT study highlight the need for strong support for patients who stray from the conventional daily-PrEP regimen. In the Bangkok cohort, participants in the daily-dosing arm of the trial achieved an 85% coverage of sexual events, with the twice-a-week cohort seeing an 84% coverage rate. Participants who took PrEP before and after sex saw a 74% coverage rate. The Harlem participants, however, fared much worse: 66% of those taking PrEP daily were covered for sexual events, 47% of the twice-a-week arm were covered, and 52% of those taking PrEP before and after sex were covered.

Why was there such a discrepancy in the coverage rates between the cohorts? “The Bangkok site had extensive experience with gay and bisexual men and transgender women,” Dr. Grant said. “They had been providing high-quality clinical and social services for many years, and this research was built into that framework of trust. In contrast, the Harlem site only does research, and they were working with young men of color for the first time. We have seen how PrEP use is typically highly effective when offered by community-based organizations, while research sites struggle with adherence.”

PrEP’s side effects include nausea, fatigue, gastrointestinal upsets, and headache. The 2 study cohorts experienced no significant differences in neurological or gastrointestinal side effects, although the daily-dose group at both study sites seemed to suffer more side effects around week 10. After week 10, the Bangkok group experienced fewer neurological side effects while Harlem’s were unchanged. Participants in both study sites suffered fewer gastrointestinal side effects after week 10.

The ADAPT study took place before the results of a similar study, the Ipergay study, were available. The Ipergay study, conducted in France and Canada, similarly concluded that non-daily dosing with PrEP was effective in protecting against HIV. As this wasn’t known for sure at the time the ADAPT study was getting underway, the ADAPT study participants were told that daily dosing was effective but that non-daily dosing was experimental. Because of this, the ADAPT study researchers feel that adherence to the non-daily regimens could have been compromised. Had the results of the Ipergay study been available at the time, the ADAPT researchers would have altered the dosing recommendations for the event-driven arm: Instead of recommending one dose before and one dose after sex, participants would have been instructed to take 2 tablets 2 to 24 hours before sex, another tablet the day after sex, and an additional tablet 2 days after sex. “That is important because the post-sex doses are the most likely to be missed,” Dr. Grant said.

According to Dr. Grant, the US Food and Drug Administration and Centers for Disease Control and Prevention still recommend daily dosing with PrEP because drug companies have not yet submitted the results of PrEP dosing studies for review. However, as providers have the leeway to prescribe medications as they see fit, the hope is that better communication between patients and providers will allow for non-daily PrEP dosing regimens that best fit the lifestyles of each user.


Could a New Approach Help Us to Overcome Resistance to HIV Treatment?

Clara chatted with Christian Setz, CEO of Immunologik, to find out how his company is developing a new HIV treatment that could overcome resistance to anti-retroviral drugs.

Over 36 million people are living with human immunodeficiency virus (HIV), which has led to many biotechs, including Abivax, working on better options for patients. Immunologik, a recent ‘Biotech of the Week’, is working on an alternative approach to HIV treatment that could help patients whose virus has become resistant to standard therapies, an issue that causes around 22,000 people to die each year, and stop their progression towards acquired immune deficiency syndrome (AIDS).

Unlike anti-retroviral drugs, which target viral proteins, Immunologik’s candidate, IML-106, “attacks specific cellular proteins that are crucial for the replication of HIV-1,” Setz explained. Deubiquitinating enzymes are the proteins in question and they are essential for viral propagation. Targeting them interferes with viral metabolism and replication and reduces the chances of the rapidly mutating virus developing resistance.

With the biotech taking such a different approach to HIV treatment, we wanted to find out where the idea had come from. The early research was carried out at the Erlangen Institute in Nuremberg. When inhibitors against deubiquitinating enzymes became available, the group was able to “study if these enzymes are really crucial for viral replication.” Once results confirmed their hypothesis, they began turning their approach into a new HIV treatment and founded the company in 2012.

The stages of the HIV life cycle, which provided opportunities for the development of anti-retroviral therapies.

Fast forward 6 years and the biotech has now completed its preclinical studies, during which it “identified the cellular target and established a model to study the influence of our drug ex vivo.” However, this did not come without its challenges as the biotech had to be inventive when selecting a suitable ex vivo model. Eventually, human tonsils were chosen as they contain all the relevant cells, “T cells, macrophages, dendritic cells, and so on,” for an HIV infection.

These were infected with HIV and Immunologik tested two regimens of its HIV treatment. AML-106 was either used permanently, throughout the 50-day study, or on the first and third day following infection. “In both cases, we detected a dose-dependent reduction in replication capacity,” Setz told us. In addition, at the drug’s effective doses, no toxic effects were observed.

This is just one of the challenges that Setz and his team have had to overcome since starting the company but, overall, he has enjoyed the experience “as you don’t always see something in the laboratory and then have the chance to develop it.” Looking ahead, he hopes that IML-106 will reduce the risk of resistance “by blocking cellular proteins, which have 1 million times lower risk of resistance,” boost long-term safety and improve patient compliance by making it available as a single pill.

HIV is able to enter the blood and find new cells to infect.

An HIV cure has been long sought after, so we wanted to get Setz’s opinion on some of the efforts being made in the field. However, he highlighted the difficulty in getting rid of the virus from the body: “The problem is that HIV is inserted into the genome… and your immune system cannot kill these cells as the virus is hidden… If some infected cells survive, millions of other cells can be infected.”

One example that Setz pointed out is the ‘shock and kill approach’, which combines latency-reversing agents that force the virus out of hiding with an immunotherapy that stimulates the immune system. However, he again highlighted that even this approach cannot guarantee that all HIV-infected cells will be killed, putting the patient at risk of remission.

As a result, Setz is unsure of when we may finally see a cure: “It is very challenging to develop such a therapy today. I cannot say if or when a cure will be possible but it is important to make this approach.” That means that, for now, we should be happy with better and safer treatments that help a greater proportion of those infected with HIV.

Author: Alex Dale


Intervention Mitigates New Cases of HIV Among Youth in the Criminal Justice System

A combination of risk-reducing interventions showed the ability to greatly reduce sexual risk-taking among high-risk teens in the juvenile justice system, according to a study published by Health Psychology. The study was conducted by the National Institute on Minority Health and Health Disparities (NIMHD) as part of the National Institutes of Health.

A trial called PHAT Life: Preventing HIV/AIDS Among Teens used role-playing, video games, and skill-building exercises to increase knowledge about HIV/AIDS, coping skills, and problem-solving techniques.

More than 1 million youths are involved the US juvenile justice system each year, according to the NIMHD. These individuals have a higher burden of mental illness, substance use disorder, and sexually transmitted infections (STsI) compared with teens of the general population. The study authors noted that there are limited evidence-based interventions that address this discrepancy.

Included in the clinical trial were 310 urban teens aged 13 to 17 years who were on probation in Cook County, Chicago. The authors noted that 66% of participants were male and 90% were African American.

Individuals were randomized to enroll in PHAT Life or an intensive health information program, both of which included 8 sessions given over 2 weeks at 4 detention-alternative afterschool programs, according to the study.

The researchers tracked the degree of condom use and the number of sexual partners in the 6 months before and after PHAT Life. Participants completed a baseline assessment before the intervention and again after 6 months.

Among those who reported the highest-risk sexual behavior at baseline, participants in PHAT Life were more than 4 times more likely to report a decrease in the number of sexual partners and an increase in consistent condom use compared with those in the other cohort, according to the study.

Among participants who reported having sex prior to age 12, those in the PHAT Life cohort had significantly fewer sexual partners after 6 months compared with control group participants.

“These findings reinforce the need for effective HIV/AIDS prevention strategies among vulnerable populations. Programs like this present opportunities to use effective methods, which result in continual benefits,” said Eliseo J. Pérez-Stable, MD, director of National Institute on Minority Health and Health Disparities.

The CDC reported that 1 in 5 new cases of HIV in the United States in 2015 were among youth aged 13 to 24. This population also accounts for half of all new STIs, which suggests they may also be at a high risk for HIV infection.

“Uniquely tailored interventions like PHAT Life that reduce adolescent risk behavior are essential to mitigate young offenders’ poor long-term trajectories. Limited resources require evidence-informed decisions about who can benefit the most from HIV-prevention efforts,” said lead researcher Geri Donenberg, PhD. “Our findings suggest that PHAT Life can reduce sexual risk among the highest-risk teens.”

Next, the researchers plan to identify how to spread PHAT Life resources to ensure the program is sustained in the juvenile justice system, according to the study.

Author: Laurie Toich

National Prevalence of HIV/ AIDS Reportedly Decreased

Addis Ababa February 22/2018 National prevalence of HIV and AIDS has reportedly decreased, according to a news survey out of the Central Statistics Agency (CSA).

A workshop on the 4th Ethiopian Demographic and Health Survey has kicked off  in Addis Ababa.

The survey covers the period from 2005 up to 2016, was conducted for a period of six months in nine regional states and two city administration on a sample survey on 30,133 respondents with age range between 15 and 49.

According to the survey which was presented by Yemane Getaneh, a senior research at the Ethiopian Institute of Public Health, the prevalence of HIV and AIDS was 1.4 percent in 2005 and has been reduced to 0.9 percent in 2016.

In 2005, the prevalence of the virus among women of the specified age was 1.9 percent and in 2016 it was reduced to 1.4.

The prevalence of the virus among men during the same period  was reduced from 0.9 percent to 0.6 percent in 2016.

Figures for the above mentioned period regarding men and women for the same period largely indicate the overall reduction in the prevalence of the disease.

The overall reduction in the prevalence of the disease is attributed to the expansion of service delivery in counseling and provision of ART facilities

HIV and AIDS prevalence in the urban centers of the country stands at 2.9 percent while figures for rural areas show 0.4 percent indicating seven fold prevalence in urban centers compared to the rural areas.

Resorting to multiple sexual partnerships, unusual sexual practices, low level of condom usage had exacerbated the prevalence of HIV and AIDS in the urban centers of the country.

The prevalence among widows and single persons was reportedly low.

Yemane added that Gambela State registered the highest level of prevalence with 4.8 percent.

Speaking on the occasion, CSO Executive Director Biratu Yigezu said that the findings of the research could be an input for researchers, academicals and development workers.

The survey was funded by the Ministry of Health, USAID and other development partners.


Seasons of Risk: Why Gay and Bisexual Men Quit Taking PrEP


Entering a relationship and reducing one’s number of sexual partners are the two most common reasons why gay and bisexual men choose to discontinue pre-exposure prophylaxis (PrEP), a longitudinal study has shown.

Researchers assessed PrEP use and discontinuation in 1,071 gay and bisexual men from across the country with an online survey repeated every six months. They followed the group for two years and found that 18% of men discontinued PrEP during this time span. A total of 31 study participants provided a written explanation justifying why they decided to quit taking PrEP.

The majority of men who quit PrEP explained that they no longer needed PrEP because they engaged in fewer sexual risk behaviors. These men reduced their risk of HIV infection in a variety of ways, including entering “monogamous” relationships, using condoms with HIV-positive partners, and refraining from receptive anal sex (bottoming). One participant, a 52-year-old white male, added that he decided to quit PrEP after becoming infected with an STI.

“I found out that I had contracted chlamydia,” he said. “I had been solely focused on just avoiding HIV, and I was reminded about the many other risks. So I decided to reduce my number of sexual partners and other risky behaviors.”

Approximately one-third of men quit taking PrEP due to cost and difficulty with insurance coverage. One participant, a 22-year-old Latino male, noted that his insurance would not pay for PrEP even though he had a prescription. Another participant, a 52-year-old white male, added that he quit PrEP to save his $50 copay.

The rest of the participants – about one-fifth of men – decided to quit PrEP due to either medication side effects or adherence difficulty. Even the anticipation of future side effects was sufficient to induce one participant, a 24-year-old Latino male, to quit PrEP.

“I didn’t want to needlessly have such a powerful medication circulating in my bloodstream,” he said.

Results were published in the journal AIDS and Behavior in February. Thomas Whitfield, a doctoral student at Hunter College and lead author of the study, emphasized that researchers shouldn’t focus too narrowly on getting more people on PrEP.

“We need to go further and assess why people who are still at-risk stop taking PrEP,” said Whitfield. “We found that about half of the individuals stopped taking PrEP because they no longer perceived themselves to be at risk. It is absolutely possible that their risk behavior has changed, and some participants even stated they would begin again if their risk behavior increased, which supports the theory that gay and bisexual men have seasons of risk.”

Still, Whitfield pointed out that being in a relationship doesn’t necessarily protect against HIV infection, which is shown by the high percentage of seroconversions that take place in people in relationships.

Survey results also revealed that unemployed gay and bisexual men are nearly five times more likely to discontinue PrEP.

“There are going to be people who are in between jobs at times and it’s important they still have access to this medication,” added Whitfield. “We need to find ways to fill these gaps so that people are able to continue protecting themselves in the most effective ways. Losing your job, or not being able to afford your copay, should not put you at higher risk for HIV.”

Although PrEP continues to gain in popularity, these findings highlight that barriers to PrEP continue beyond starting the medication. As always, talking to one’s physician about risk factors for HIV infection is an important part of making informed health decisions, including whether or not to discontinue PrEP.



Tattoo programs in Canada’s prisons would help curb hepatitis, HIV: Memo

Corrections ombudsman Ivan Zinger says tattooing in prison frequently involves sharing dirty equipment — which is linked to higher rates of hepatitis C and HIV among inmates.

Setting up tattoo parlours and needle-exchange programs in federal prisons would help reduce hepatitis C rates, the Correctional Service told Public Safety Minister Ralph Goodale.



Setting up tattoo parlours and needle-exchange programs in federal prisons would help reduce hepatitis C rates, the Correctional Service told Public Safety Minister Ralph Goodale.

A Correctional Service memo obtained under the Access to Information Act advises Public Safety Minister Ralph Goodale the proposals “warrant consideration” to round out existing and planned measures to fight hepatitis and HIV in prison.

Prison tattooing and needle-exchange programs for drug users have generated intense controversy over the years and the March 2017 memo says detailed research should be carried out before embarking on a syringe needle program, in particular, “to avoid unintended and negative consequences for inmates.”

In response to questions, the prison service and Goodale’s office said Monday they were exploring options “to better prevent, control and manage infectious diseases” but did not provide details about possible tattoo or needle programs.

The current approach to prevent and control blood-borne and sexually transmitted infections includes screening, testing, education, substance-abuse programs and treatment.

The prevalence of HIV among federal inmates decreased to 1.19 per cent in 2014 from just over two per cent in 2007, according to the memo. But it stood at six times that of the general Canadian population.

Similarly, the proportion of inmates with the hepatitis C virus fell to 18.2 per cent in 2014 from 31.6 per cent in 2007. Yet the incidence was still about 23 times that of the general population.

Federal prison ombudsman Ivan Zinger recently called on the Correctional Service to bring back its safe tattooing program.

His annual report said tattooing in prison frequently involves sharing and reusing dirty homemade equipment — linked to higher rates of hepatitis C and HIV among inmates — and there is often no safe means of disposing of used tattoo needles.

In 2005, the prison service began a pilot program involving tattoo rooms in six federal institutions, but two years later, the Conservative government of the day ended it.

The memo to Goodale says an internal evaluation of the pilot indicated that it increased awareness about disease prevention and had the potential to reduce exposure to health risks. In addition, neither inmates, staff, nor volunteers reported health and safety concerns with the program.

“In fact, the evaluation indicated that the majority of staff believed the initiative made the institution safer for both staff and inmates.”

Safer tattooing could reduce hepatitis C virus transmission within federal prisons by 17 per cent a year, the memo says.

The Correctional Service has tried to keep illicit drugs from entering prisons, but acknowledges that some still make their way into penitentiaries. Although the prison service has made bleach available, it has drawn the line at offering clean needles.

A program to provide clean drug-injection needles to prisoners could reduce the spread of hepatitis C by 18 per cent a year, the memo says.

In the case of both safer tattooing and needle programs, it wasn’t possible to gauge the potential effect on HIV prevalence or spread among prisoners due to the existing low HIV rates.

The Canadian HIV/AIDS Legal Network has long argued for needle-exchange programs in Canadian prisons. However, Correctional Service officials have raised concerns about syringe needles being used as weapons.

The memo to Goodale recommends weighing the effect a needle program might have for workplace safety regimes, and it suggests more research be done on the effectiveness of such an initiative from both clinical and cost standpoints.

Author: Jim Bronskill


The Unintended Consequences of AIDS Survival

On World AIDS Day 2016, the first chronicle of its kind describing a series of unique health and psychosocial challenges in HIV/AIDS survivors in the United States is available to download online ( The Unintended Consequences of AIDS Survival is a 24-page status report that calls attention to the lives of people living with AIDS, particularly long-term survivors, who feel their psychosocial needs are not prioritized in the AIDS landscape. This, added to earlier physiologic aging now widely studied in survivors with years of traumatic stress and unprocessed grief, has essentially become the rallying cry for a new HIV movement.

The paper also depicts a graphic representation of major AIDS historic time points side by side with epidemiological data, in order to provide a reality check of emotions throughout the epidemic. Evidence gathered from behavioral research, clinical science, epidemiology, recent articles from local press, and AIDS publications are referenced.

An important component of the report shows how San Francisco once again leads national HIV/AIDS trends. Beginning in 2013 a few AIDS activists banded together to mobilize survivors in order to raise awareness, provide a forum, and create change in their lives. Firsthand testimony was gathered at town hall forums, policy advocacy meetings, weekend retreats, and in support groups and social gatherings. By describing these survivor mobilization efforts in this document, other jurisdictions across the country will learn lessons that can be tailored for their own communities.

Chris Bartlett, Executive Director of the William Way LGBT Community Center in Philadelphia and a member of The Reunion Project national steering committee said, “The Center, partnering with other community-based organizations, has taken the lead in building a vibrant community of long-term survivors in our region, who are committed to thriving as elders and building a powerful intergenerational response to the current needs of people growing older with AIDS.”

The report also aims to further educate, mobilize, promote discussion, and stir creation of new research, new interventions, policy recommendations, advocacy and programming across the country. “Once mobilized to fight for survival, long-term survivors continue to lead in fostering meaningful social ties and resilience,” says Robert M. Grant of the Gladstone Institutes and the San Francisco AIDS Foundation. “Their stories serve to bring us together to heal from the trauma and fear of the early HIV/AIDS epidemic, and to help us face the emerging challenges of aging, changing health care, employment, and isolation.”

As more survivors come out of isolation to tell their stories, each one is unique, some woeful and horrific, but always revealing. As more people become aware of the complicated issues, and recognize there is something they can do to change, they are emerging as a new movement once ravaged, now re-energized.

Author Matthew Sharp, a 28-year AIDS survivor, is uniquely qualified to pen this particular survivor story as an eyewitness on the front lines in the AIDS fight. He is one of a handful of AIDS activists leading survivor mobilization efforts nationally with The Reunion Project, a series of ongoing town hall summits taking place around the country. The Reunion Project is supported by Bristol-Myers Squibb and Test Positive Aware Network (TPAN), publisher of Positively Aware magazine. Bristol-Myers Squibb commissioned Sharp, who is one of the founders of The Reunion Project, to author the paper.


Global Health Sector Strategy on Viral Hepatitis: What does it mean for Canadians?


In 2016, the World Health Organization (WHO) released the Global Health Sector Strategy on Viral Hepatitis, 2016–2021.1 The goal of the strategy is to eliminate viral hepatitis as a major public health threat by 2030. This is the first global strategy on viral hepatitis and it lays out the targets and approaches we need to meet this ambitious goal.

Canada has signed on to this strategy.2 Achieving the strategy’s targets will require important changes in the Canadian hepatitis response. We all have a role to play. This article will detail the strategy targets, examine how Canada is doing in these target areas, and discuss some key shifts in hepatitis C programs and policies that will be necessary to achieve these targets by 2030.

What is the global strategy on viral hepatitis and why is it important?

A global health sector strategy on viral hepatitis is critical considering the scale of the hepatitis pandemic, as well as the limited and fragmented response at the national and global levels. The viral hepatitis pandemic world-wide is responsible for an estimated 1.4 million deaths per year from acute infection and hepatitis-related liver cancer and cirrhosis.1 Hepatitis B accounts for 47% of these deaths and 48% are attributed to hepatitis C.1

The WHO strategy is the first global health strategy on viral hepatitis (hepatitis A, B, C, D and E). The strategy focuses particular attention on hepatitis B and C because of the relatively large public health burden they present.

The strategy asserts that ending the hepatitis pandemic is feasible. The strategy’s vision is “A world where viral hepatitis transmission is halted and everyone living with viral hepatitis has access to safe, affordable and effective prevention, care and treatment services.”1 Aside from setting a specific vision, targets and priority actions for the global community, the strategy also details some programming and policy interventions needed to successfully achieve its targets. These interventions will be discussed later in the article. The strategy provides a strong road map and clear direction to all those engaged in the hepatitis response.

What are the global strategy targets and how is Canada doing in these areas?

The strategy outlines five strategic directions and sets global targets to help shape national goals and targets. The first strategic direction calls for each country to collect data on the epidemic at the national level and to develop specific national targets and an evidence-based national hepatitis plan.

Despite having signed on to the global strategy, Canada does not currently have a national hepatitis strategy and has not yet developed specific national targets.

Although Canada has not developed specific national targets, the following global targets outlined in the strategy provide a starting place to examine how Canada is doing in some of the impact and service coverage targets:

Impact targets

  • Incidence: By 2030, there will be a 90% reduction of new cases of chronic viral hepatitis B and C infections.

There is no data available on the number of new cases (incidence) of hepatitis B and C in Canada required to monitor this WHO target; however, Canada does collect data on new diagnoses. This data will be used to examine how Canada is doing, but it should be noted that this number includes the diagnoses of both new and existing infections and is not a true measure of incidence.

Between 2005 and 2014, the rate of reported diagnoses of hepatitis C decreased steadily from 40.2 per 100,000 people to 29.3 per 100,000. This represents a drop from 12,990 diagnoses in 2005 to 10,458 in 2014.3 To accomplish a 90% reduction in the number of new hepatitis C diagnoses by 2030, we would have to see a drop to 1,046 diagnoses.

A total of 302 new acute hepatitis B diagnoses were reported in 2005, corresponding to an overall rate of 1.0 per 100,000, compared to 178 new diagnoses in 2014 (a rate of 0.5 per 100,000). To accomplish a 90% reduction in the number of new acute hepatitis B diagnoses by 2030, we would have to see a drop to 18 diagnoses.

There were 752  diagnoses of chronic hepatitis B reported in 2005, representing a rate of 5.9 per 100,000, which increased to a high of 4,634 diagnoses in 2012 (a rate of 13.6 per 100,000).3 Since then, the number of reported diagnoses has declined to 4,058 in 2014 (a rate of 12.0 per 100,000). To accomplish a 90% reduction in the number of new diagnoses of chronic hepatitis B by 2030, we would have to see a drop to 406 diagnoses.

  • Mortality: By 2030 there will be a 65% reduction in mortality rates

In 2013, no deaths from acute hepatitis C infection were reported in Canada (as compared to 33 in 2012); however, 465 deaths were attributed to chronic hepatitis C infection.3 It is likely that there is considerable underestimation of the number of deaths related to hepatitis C because of potential misclassification on death certificates. To accomplish a 65% reduction in deaths related to hepatitis C by 2030, we would have to see a drop to 163 deaths.

In 2013 (the most recent year for which mortality data were available), acute hepatitis B infection was documented as the leading cause of death in 18 people in Canada, and a further 50 deaths were attributed to chronic hepatitis B. 3 Initial observations on mortality data suggest a rising number of deaths attributable to chronic hepatitis B infection between 2011 and 2013. The true magnitude of deaths related to hepatitis B­ is also likely higher due to potential misclassification on death certificates. 3 To accomplish a 65% reduction in hepatitis C related deaths by 2030, we would have to see a drop to 24 deaths.

Service coverage targets

  • Prevention: By 2030, there will be an average of 300 sterile needles and syringes provided per person who injects drugs per year.

Coverage estimates for Canada estimate that 148 needles/syringes are distributed per person who injects drugs.4 There are no needle and syringe programs operating inside prisons in Canada.5 Based on this data, Canada will have to double the number of needles distributed per injector per year to meet the target.

  • Prevention: By 2030, there will be 90% childhood hepatitis B vaccine coverage

In Canada’s provinces and territories, the hepatitis B vaccine is administered either as part of routine infant immunization or through school-based programs. For jurisdictions with a three-dose hepatitis B infant immunization program, the coverage estimate was 75% by age seven. By 17 years of age, an estimated 88% of Canadian children had at least one dose of the three-dose hepatitis B vaccine.6 As we continue to make progress in vaccination coverage for hepatitis B, this target may be realistic for Canada to meet by 2030.

  • Prevention: By 2030, 100% of blood donations are screened in a quality-assured manner

Blood donations in Canada are routinely screened for HIV, hepatitis B, hepatitis C and other blood-borne pathogens. There have been no recent transmissions of these infections by blood transfusions.7 Canada has met this target.

  • Prevention: By 2030, 90% coverage of hepatitis B virus birth-dose vaccination or other approach to prevent mother-to-child transmission

It is recommended that all pregnant women in Canada are offered a test for hepatitis B during prenatal visits or at the time of delivery.8 All infants born to mothers with hepatitis B are offered the hepatitis B vaccine.8 While no estimates are available to measure whether Canada has met this target, there are systems in place to meet it by 2030.

  • Prevention: By 2030, 90% of injections will be administered with safety-engineered devices in and out of health facilities

This indicator related to injection safety is more relevant in low-and middle-income countries where there is ongoing risk of hepatitis transmission through the medical system. In Canada most injections are provided with a new single use syringe and re-use is extremely rare. However, there is a residual risk of hepatitis transmission to healthcare workers through needlestick injuries, which is why safety-engineered devices are recommended.

Safety-engineered devices have built-in safety controls that reduce and potentially prevent needle stick injuries for healthcare workers taking blood samples or through other injections. In Canada, regulations relevant to the prevention of needle stick injuries are developed by provincial authorities. Not all provinces have passed legislation mandating the use of safety-engineered devices. For Canada to achieve the WHO target, all provinces and territories should consider the use of safety-engineered devices in and out of health facilities.

  • Testing: By 2030, 90% of people living with hepatitis C and hepatitis B will know their status

According to estimates from the Public Health Agency of Canada, an estimated 44% of people infected with hepatitis C do not know they have hepatitis C (and an estimated 54% do not know they have hepatitis B).9 This tells us that we have a long way to go to meeting the target of 90% by 2030. There needs to be increased uptake of new testing technologies, public awareness campaigns and innovative approaches to meet this target.

  • Treatment: By 2030, 80% of all eligible persons with chronic hepatitis B or C will be treated.

According to a 2013 report by the Canadian Liver Foundation, less than 10% of people with hepatitis B and less than 25% of people with hepatitis C have been treated.10 However, now that highly effective and short course direct-acting antiviral (DAA) therapies are available for the treatment of hepatitis C and are on formularies across Canada, the number of people receiving hepatitis C treatment should increase. This current level of treatment coverage tells us that we have a long way to go to meeting the target of 90% for both hepatitis B and C by 2030.

Monitoring Canada’s Progress

It is crucial that Canada starts to systematically collect and monitor national-level data to show progress towards these indicators in an ongoing fashion. Currently these data do not exist in any systematic or coordinated fashion.

In terms of assessing where Canada is at currently and what else is needed to achieve the WHO global strategy targets, the most comprehensive data and modelling come from British Columbia. British Columbia has developed a cascade of hepatitis C care11 using population-level data from the B.C. Hepatitis Testers Cohort. The cascade of care demonstrates the numbers of individuals with hepatitis C who get tested and subsequently move through the continuum of hepatitis services towards retention in care, treatment and cure.11

The B.C. cascade is likely a relevant snapshot of how Canada is currently doing at each stage of the continuum, and signals where there are gaps. Notably, the WHO global strategy uses the cascade of care as an organizing framework to underscore the specific actions necessary to achieve the global targets.

From the B.C. cascade of care for 2012, shown in Figure 1, it is evident that treatment uptake is particularly low. Only 56% of the estimated number of people living with hepatitis C in B.C. have had a confirmatory RNA test, only 12% have started treatment, and only 7% have been cured. The cascade was developed during the interferon era of treatment, so it is expected that treatment uptake will increase in the coming years as treatment is easier to take and of a shorter duration.

Figure 1. The B.C. hepatitis C cascade of care (2012)

Programming and policy implications

To achieve the global viral hepatitis targets laid out in the WHO strategy, important programmatic and policy shifts need to happen in Canada. The WHO strategy outlines broad priority actions to be taken by each country and the WHO. The proposed actions are intended to guide country efforts, with countries defining and implementing specific actions that are most appropriate to their respective hepatitis epidemics.

This section utilizes the Canadian national-level hepatitis C data, as well as the more specific B.C. cascade of care data to tease out some key actionable steps for Canadian hepatitis C service providers and policy makers.

Hepatitis C prevention

In Canada, the hepatitis C epidemic is most prevalent amongst people who use injection drugs.12 The WHO strategy has several priority actions related to harm reduction. It recommends that countries implement a comprehensive package of harm reduction services, integrate hepatitis C services into harm reduction programs, and address legal and institutional barriers to the provision of harm reduction services.

The data suggests that Canada has a long way to go to reach optimal comprehensive harm reduction coverage, including meeting the target of 300 new needles for every person who injects drugs.

Despite ongoing barriers to providing comprehensive harm reduction services across Canada, it is important that organizations consider the following approaches:

  • Provide a comprehensive package of harm reduction services and programming including unlimited provision of sterile needles and syringes, as well as other drug equipment such as crack pipes; access to opioid substitution therapy; risk reduction education; and broad drug user health services as recommended in the Best Practice Recommendations for Canadian Harm Reduction Programs.13
  • Provide clear programming guidelines on how to improve provision of harm reduction services,13 including how to tailor harm reduction services to local context and communities being served, ensuring culturally relevant programming for priority populations, and expanding programming to rural and remote areas.
  • Link and integrate hepatitis C services within harm reduction and community health services.
  • One of the most significant challenges to accessing services is existing laws and policies, which criminalize drug use, drug possession and ultimately people who use drugs. One of the recommendations made in the global strategy is to address legal and institutional barriers to the provision of harm reduction services. Addressing the de-criminalization of drug use is a policy change that might be considered.

Hepatitis C testing

The WHO strategy calls for a high diagnoses rate for hepatitis C. A related priority action outlined in the strategy is to integrate viral hepatitis testing into national hepatitis policies and guidelines that define priority populations, as well as testing locations and strategies.

Broadening public education and testing efforts in Canada is essential. It is also critical to ensure that once people are tested, they are linked with care and treatment options. Canadian testing guidelines do not recommend age cohort testing, which misses a significant proportion of the undiagnosed population in Canada.14 Despite these limitations, wherever possible the following approaches can be useful to increase front-line testing:

  • Partner with other organizations and services to help enable seamless and timely linkage to testing, treatment and care.
  • Provide health navigation support to clients who have been tested at one site and are being linked to care at another organization.
  • Expand public and tailored education and testing efforts, including offering hepatitis C testing in new sites frequented by priority populations, including harm reduction programs, shelters, newcomer programs, community centres, and as part of testing fairs.
  • Integrate new testing technologies and approaches into practice such as dried blood spot testing and point of care testing.

Hepatitis C treatment

The WHO target of providing treatment to 80% of all eligible persons by 2030 will require important programming and policy shifts in Canada. The most significant gap along the continuum of care in Canada is treatment uptake.11 The availability of highly effective oral therapies on provincial and federal formularies across Canada creates an opportunity to substantially increase treatment roll out. The key will be to make these treatments accessible to priority populations, as well as making re-treatment accessible in the case of re-infection. Concerns about re-infection are often cited as a reason for not offering treatment to individuals at high risk of re-infection, yet there is actually strong evidence to suggest that offering treatment to the most high-risk individuals is instead the most effective approach to achieving elimination of hepatitis C at both the individual and population level.15

Several ways this can be achieved include:

  • In the case of re-infection, offer re-treatment without discrimination.
  • Utilize ‘bring a friend’ strategies within organizations offering treatment, to increase treatment scale-up within high-risk sub-populations.
  • Expand the reach and scope of hepatitis C treatment programs to underserved priority populations and target small local networks with a high prevalence of hepatitis C. This can include providing comprehensive harm reduction services to prevent re-infections.16

Health equity across the hepatitis C continuum of care:

Delivering for equity is another one of the five strategic directions in the WHO strategy. Structural barriers such as ‘poverty, discrimination and criminalization, drug dependence and poor mental health’1 increase vulnerability and prevent equitable access to hepatitis C services. In Canada, stigma, racism and discrimination within the healthcare system can deter certain populations from accessing services – in particular Indigenous peoples, people who use drugs, and other stigmatized groups.17 When marginalized and stigmatized populations do access services, the services can be culturally or structurally inappropriate and ineffective at serving those populations. The WHO strategy calls for the creation of institutional and community environments that make it safe for people to access hepatitis services, which includes involving people most affected in the planning and delivery of services. It is also critical that hepatitis services address the social factors, such as poverty, trauma and stigma, that can impact participation in sexual and drug use practices that place people at greater risk of infection.

Activities that can increase access and relevance of services for priority populations include:

  • Involving people with lived experience of hepatitis C and priority populations in all stages of program planning and delivery.
  • Developing or partnering with services provided by and for communities most affected by hepatitis C.
  • Providing or referring to social services as part of the hepatitis C continuum of care including employment, housing, mental health, and addiction and harm reduction services.

Author:Suzanne Fish and Melisa Dickie



Gianni Versace Has HIV in a New TV Series. What’s the Real Story?

The fashion icon and his family have never publicly disclosed he had the virus.

The second episode of The Assassination of Gianni Versace: American Crime Story begins in 1994, three years before the fashion designer was murdered by Andrew Cunanan. As portrayed in this episode of the FX miniseries, Versace is being treated for HIV. This is two years before lifesaving treatment came along (in 1996), and Versace seems very ill.

In real life, though, his health problems at that time were attributed to an inner-ear cancer, not HIV. In fact, as Vanity Fair reports, the Versace family has long denied that the fashion icon had HIV. So why did the TV series pursue the HIV storyline?

It’s based on a book by Maureen Orth titled Vulgar Favors: Andrew Cunanan, Gianni Versace, and the Largest Failed Manhunt in U.S. History. Orth says she spoke with a detective who saw Versace’s autopsy report.

Tom Rob Smith, a writer for the TV show, tells Vanity Fair that he confirmed Versace’s HIV status with off-the-record sources. “We weren’t approaching it as a piece of salacious gossip, nor was Maureen Orth,” he says. “She has no agenda or reason to push any point of view. She was interested in unpacking some of the myths around the murder, such as that Andrew had AIDS and was killing because of it. In fact, Andrew, this destroyer of life, did not have AIDS, and the person who did have HIV was this great creator and celebrator of life.”

(As ABC reported in 2014, FBI documents claim that before killing five people in four states in 1997, Cunanan had expressed fears that he had AIDS—and that he was out for revenge on anyone who might have been the source of his HIV. However, according to the same report, Cunanan had never been tested for the virus.)

The TV series and book offer several reasons why the family might have wanted to keep an HIV diagnosis a secret. Besides the obvious discrimination, stigma and homophobia, there was the fact that Versace was about to take his company public. Since he was its head and namesake, the company might have been valued at less if everyone thought he had a life-threatening illness.

As Orth pointed out in her book, it seems particularly tragic that, thanks to the advent of modern HIV meds in 1996, Versace survived a terrible sickness in 1994 and 1995 only to be murdered in 1997.

“I think the Versaces will like some of what we do,” the show’s producer Ryan Murphy told journalists in a report in New York Magazine’s “I think it’s moving and powerful, and I don’t think there should be any shame associated with HIV.”

Author: Trenton Straube


Openly gay US marine announces run for house seat in Alabama

“I look forward to expanding my lifetime of service as I announce my candidacy for State House of Representatives District 54. We are better together. Let’s get to work!”

Openly gay US marine Neil Rafferty has made the decision to run for a seat in Alabama State House District 54.

Rafferty – who hails from Birmingham, Alabama – made the announcement on his Facebook page, and revealed how he came to the decision.

“Nine days ago, I was approached by a dear friend who asked if I would consider running to fill the vacant seat for Alabama State House District 54. In the past week, I’ve spent many hours in conversation with family and friends, but more importantly, I’ve asked myself how can I best serve my community,” he said.

“On Friday, I traveled to Montgomery to complete qualifying paperwork to run. I look forward to expanding my lifetime of service as I announce my candidacy for State House of Representatives District 54. We are better together. Let’s get to work!”

The marine is running for the seat vacated by Democrat Patricia Todd – the state’s first gay legislator – who announced in January that she would not seek reelection.

If elected, Rafferty would become Alabama’s first openly gay congressman.

Rafferty’s story went viral last year when he joined the marines after his boyfriend Michael Rudolph left for deployment.

In a StoryCorps podcast featured on the Obama Foundation website, Rudolph said to Rafferty: “I had already deployed twice, both times as a closeted gay man. I remember coming back from Iraq the second time. And I wake up, and my head is in your lap. I’m trembling and you’re rubbing my head and you’re telling me, ’You’re safe, I’m here.’ You were my comfort, you were my rock.

“Just the fact of you seeing what war did to me and you looking at me and saying, ’I don’t want you to be alone next time you go through that. I want to be with you.’”

Rafferty then enlisted three weeks later, and told Rudolph: “Well. I love you. So it was pretty worth it.”

Author: Sam Damshenas