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KL!! Seek and Treat for Optimal Prevention of HIV/AIDS ! STOP HIV/

AIDS "

Julio Montaner

BC-Centre for Excellence in HIV/AIDS, Providence Health Care Division of AIDS, University of British Columbia

International AIDS Society

While an outright cure for a preventive vaccine for HIV / AIDS remain elusive, remarkable ad- vances in HIV treatment have been achieved over the past two decades. Most significant among these advances is the development of highly active antiretroviral therapy"HAART#. HAART can fully suppress HIV replication and therefore render the number of viral copies present in a patients blood undetectable, as measured by commercially available plasma viral load assays. Since"&&$, the use of HAART dramatically reduced HIV/AIDS related morbidity and mortality.

More recently, we have provided evidence that the viral load suppression achieved by HAART has a substantial impact on the transmission of HIV. Specifically, in August#!!$, we published a view- point article in 1:7 +3?57Dthat outlined the expansion of HAART coverage to all those in medical need as a key strategy to dramatically reduce HIV transmission to those at risk. We further proposed that HAART expansion in addition to preventing AIDS morbidity and mortality, would becomecost- averting as it would virtually eliminate vertical transmission of HIV, and dramatically reduce HIV transmission by all routes"Lima et al, JID,#!!%#. More recently, we published"Wood et al, British Medical Journal,#!!&#the first study demonstrating the role of HAART in the prevention of HIV transmission in injection drug users in the Downtown Eastside of Vancouver. Treatment as Preven- tion has now gained the support of the international community, including investigators based at the World Health Organization"WHO#"Granich et al, The Lancet,#!!&#!

The expansion of HAART currently underway in British Columbia, Canada, aims to increase cover- age among clinically eligible HIV-positive individuals on treatment, monitoring the impact of such ex- pansion on HIV incidence, as well as AIDS morbidity and mortality over several years. Our mathe- matical models suggest that this will generate approximately a substantial decline in AIDS related morbidity and mortality and also a decrease in HIV incidence. We have entitled this initiative 077<

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KL!! State of the art on anti-HIV chemotherapy

Erik De Clercq

Rega Institute for Medical Research, K. U. Leuven

There are at present exactly twenty-five compounds that have been formally approved for the treatment of retrovirus, i.e. HIV, infections:$nucleoside reverse transcriptase inhibitors!NRTIs": zi- dovudine, didanosine, zalcitabine, stavudine, lamivudine, abacavir, and emtricitabine;"nucleotide re- verse transcriptase inhibitor!NtRTI": tenofovir!in its oral prodrug form, tenofovir disoproxil fu- marate";#non-nucleoside reverse transcriptase inhibitors!NNRTIs": nevirapine, delavirdine, efavirenz, and etravirine;"!protease inhibitors!PIs": saquinavir, ritonavir, indinavir, nelfinavir, am- prenavir, lopinavir, atazanavir, fosamprenavir, tipranavir, and darunavir;"co-receptor inhibitor!CRI": maraviroc;"fusion inhibitor!FI": enfuvirtide; and"integrase inhibitor!INI": raltegravir. Other com- pounds expected to be approved for the treatment of HIV infections in the near future are the NNRTI rilpivirine, the CRI vicriviroc, and the INI elvitegravir. To obtain synergistic activity, enable lower dosage levels, thus minimizing toxic side effects, and particularly to reduce the risk of drug resistance development, common wisdom dictates that the HIV inhibitors should be used in drug combination regimens. While, given the number of compounds available, the drug combinations that could theo- retically be envisaged are uncountable, the only triple-drug combination that has so far been formu- lated as a single pill to be taken orally once daily, namely Atripla!, contains the NtRTI tenofovir diso- proxil fumarate, the NRTI emtricitabine and the NNRTI efavirenz.

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MSM $ Men who have sex with men % Networks in Asia

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&@ R!Jeffrey Grierson

$Senior Research Fellow, Charles La Trobe Fellow in Male to Male Sexual Practice in the Asia/Pacific Region/Australian Research Centre in Sex, Health & Society, La Trobe University%

@[!Gay Sauna Networks: Understanding Sex on Premises venues for prevention and support interventions

Kyung-Hee Choi

$Center for AIDS Prevention Studies, University of California%

@[!Feasibility of lmplementing and Assessing an HIV Risk Reduction Education Network Intervention with Men Who Have Sex with Men in Nanjing, China Shui Shan LEE

$Stanly Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong%

@[!The connectivity of MSM in Hong Kong: findings from the SNA survey among HIV positive MSM

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SSY !!" Gay Sauna Networks: Understanding sex on premises venues for preven-

tion and support interventions

Jeffrey Grierson

Senior Research Fellow, Charles La Trobe Fellow in Male to Male Sexual Practice in the Asia ! Pacific Region

Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne Australia

Background: Sex on premises venues"SOPV#are a primary site for health promotion interventions for gay men and other MSM. Critical to this is an understanding of the ways in which the physical and social environ- ments shape, constrain or co-vary with sexual practice.

Methods: Detailed interviews with SOPV patrons detailed the nature, duration and sequencing of the sexual interactions during the mens most recent visit to an SOPV. The data describes trajectories of engagement with sexual possibilities during this visit.

Results:#")men completed telephone interviews within%(hours of their visit to SOPVs in Melbourne, Aus- tralia. Interviews detailed the pattern of visits using time sequences that plotted their venue trajectory.

Each sexual episode was detailed in terms of partner characteristics, sexual practices and sequencing. (#$ of men were HIV-ve.&($of the men were single and#'$had a regular male partner. Visits lasted from one and four hours. Sex-related settings accounted for'!$of mens time.'%$of mens time did not involve a sexual interaction. Sexual encounters lasted an average of#&minutes. Over half of the encounters took place in cubicles. Cubicles accounted for($). $of encounters involving anal intercourse"protected and un- protected#. Partners age was more likely to be undetermined in cruising areas. Partners were assessed as somewhat older in cruising and wet areas compared to cubicles. Partners HIV status was unrelated to site.

Conclusions: Detailed examination of sexual trajectories in SOPVs provides useful contextual data for target- ing and delivery of health promotion interventions.

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SSY !!" Feasibility of Implementing and Assessing an HIV Risk Reduction Education

Network Intervention with Men Who Have Sex with Men in Nanjing, China

Kyung-Hee Choi

, Juan Jiang

, Ningxiao Cao

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Center for AIDS Prevention Studies, University of California, San Francisco, USA

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The Institute of Dermatology, Chinese Academy of Medical Sciences, Nanjing, China

Background: In China, men who have sex with men#MSM$are at high risk for HIV. However, there are few evidence-based HIV prevention interventions available for Chinese MSM. We designed and pilot-tested an HIV risk reduction network intervention with MSM in Nanjing, China.

Methods: We recruited and trained"(MSM as Social Network Health Advocates. These"(Advocates re- cruited*(eligible MSM from their social networks#&(. Recruits per Advocate$for assessments. The Advo- cates also disseminated HIV prevention messages and distribute safer sex kits to their Recruits over three months. They had an option of delivering the intervention in either an individual or group format. Both Ad- vocates#N%"($and Recruits#N%*($completed questionnaires at baseline and three months after complet- ing the intervention. Of these""%participants,*(#)&&$returned for three month assessments.

Results: The"(Advocates met with'##'%&$,)$#)&&$, and(!#(#&$of the*(Recruits during the first, second, and third month of intervention implementation, respectively. Over the course of the three months, the Advocates distributed%*!safer sex kits#&per Recruit$to their Recruits and held a total of"%!interven- tion sessions#""'individual and#%group sessions$. The most common places that the intervention took place were tea houses"coffee shops"restaurants#$&&$!homes##'&$!and gay bars"bathhouses#"*&$. Our pilot data shows promising results. We found a reduction in sexual risk behaviors between the two as- sessment periods. The percentage of men who reported unprotected anal intercourse with men reduced from$&&at baseline to#$&at follow-up#p-value%!.!(&$. The percentage of men who reported unpro- tected anal or vaginal sex with both men and women declined from)&at baseline to!&at follow-up#p- value%!!"$. $.

Conclusions: These results suggest that a network intervention is feasible to implement and promote safer sex among MSM in China.

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SSY !! " The connectivity of MSM in Hong Kong: findings from the SNA survey

among HIV positive MSM

Shui Shan LEE

Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong

Sexual contacts in men having sex with men!MSM"is one of the main driving forces of the HIV epidemic in Asian countries. We hypothesize that the pattern of partner-sourcing, defined as the process of seeking sex partners prior to sexual practice, could be an important determinant of HIV spread. Partner-sourcing can be venue-specific, for example, through any physical locations frequented by MSM. It can also take place vir- tually through the cyberspace. A social network analysis!SNA" based approach is proposed for assessing the partner-sourcing pattern of MSM. A survey was conducted on a cohort of HIV positive MSM in Hong Kong to take stock of the partnership pattern prior to their infections. Six categories of partner-sourcing ven- ues/settings were explored sauna, toilet, sex party, bar, gathering and internet. Seventy-three MSM were assessed, the partner-sourcing profile of which were examined in a"-mode matrix, followed by their transfor- mation into one-mode networks. On the principle of the duality of people and place, MSM who sourced part- ners in the same range of venues were assumed to be more closely related to one another. This has led to the discovery of"social clusters, one of which internet-related and the other sauna-related. Comparing the geno- type resistance testing!GRT"sequences available in$%MSM,#genetic clusters could be delineated,"associ- ated with internet and!with sauna. Characteristically their virus strains in the internet-related clusters were more closely-knit compared to the sauna-related ones. The partial overlap between genetic clusters and social clusters offer a new angle for evaluating the HIV transmission potential of the MSM community.

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SL!! Epidemiology, Scientific Networking and Prevention Tasks in the Field of HIV/AIDS: the German Experience and the Competence Network for HIV/AIDS

Klaus, Jansen

Competence Network for HIV/AIDS Clinic for Dermatology and Allergology Ruhr-University Bo- chum

In Germany,#)!', newly diagnosed HIV infections were reported in#!!). This number raised con- stantly between#!!"and#!!)from"%%$, to#)!', , with a flattening since#!!'. At the end of#!!), the number of persons living with HIV in Germany is estimated as'$&!!, , there of"!,&!!persons with AIDS. The number of patients treated currently in Germany is estimated as$!!!!, .

Main risk of transmission in Germany is sex between men!MSM", with'&% in#!!), followed by heterosexual contacts!"(%", intravenous drug use!IVDU"is of minor importance!&%". New infec- tions are diagnosed predominantly in urban areas. The number of reported AIDS cases in Germany decreased heavily after introduction of HAART from about#,!!!in"**&to about&&!in#!!(, but a high number of unreported cases is assumed. The number of AIDS cases in#!!)are estimated as about""!!, . This high number is assumed to be caused by late testing and a late start of HAART.

As a national basis for HIV/AIDS related research in Germany, the Competence Network for HIV/

AIDS!KompNet"was funded in#!!#, to foster scientific collaborations on HIV/AIDS and to bring sci- entific results into practice. It combines expertise of basic, clinical and social scientists, public health experts and patients organisations. As its central instrument to picture the reality of ART and their effects in Germany, KompNet established an open, retrospective and prospective, multi-center, disease-specific and nationwide cohort study of HIV-positive patients. Currently, it covers*,%"!pa- tients and#&""$, person years!mean:#.(". A wide range of clinical and sociodemographic items are documented semi-annually. Additionally, there are extensive biobanks.

Preceded by vehement debates, prevention tasks regarding HIV/AIDS in Germany were estab- lished as life-style accepting and non-stigmatising campaigns, based on the theoretical concept of structural prevention, considering personal and social general conditions. Two complementary con- cepts of prevention were established, conducted by two specialised agencies, and continuously ad- justed:!""promotion of condom use for general population,!#"prevention tasks for specific target groups like MSM, IVDU, sex workers etc. using their specific languages and codes. Outcome is moni- tored constantly on basis of epidemiological surveillance, and representative surveys as to knowledge and behaviour. The overall campaign is assumed as highly efficient, having one of the lowest Euro- pean incidences of HIV in Germany.

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