News Sexual Health

Vatican Officials Toe The Line on Condoms At Symposium on HIV Prevention

Martha Kempner

While some had hoped this weekend's meeting would build on recent comments about condoms from the pope, Vatican officials toed the line and emphasized chastity and behavior change. 

This weekend, over 100 experts from around the world gathered for a two-day symposium organized by the Vatican’s Pontifical Council for Health Care Workers on preventing HIV and caring for those who are living with the virus. While some HIV-prevention advocates had hoped the Vatican would use this opportunity to build on recent comments by the pope suggesting a more favorable stance toward condom use for HIV prevention, Vatican officials at the symposium toed the line and emphasized chastity and behavior change.  

In November 2010, Pope Benedict XVI made comments during an interview for the book Light of the World, in which he said, in part, “there may be a basis in the case of some individuals, as perhaps when a male prostitute uses a condom, where this can be a first step in the direction of a moralization, a first assumption of responsibility.” Progressives within the church and AIDS activists hailed the comments as a first step in the loosening of the Vatican’s prohibition on condoms as part of HIV-prevention but Vatican officials quickly and repeatedly backed away from the remarks.  

Nonetheless, some hoped that the pope’s sentiments could be the starting point for a new conversation about HIV-prevention that included condoms. Michel Sidibé, the executive director of UNAIDS, mentioned the pope’s comments when he spoke on Saturday telling attendees: “This has helped me to understand his position better and has opened up a new space for dialogue.” He went on to say:

“Yes, there are areas where we disagree and we must continue to listen, to reflect and to talk together about them. But there are many more areas where we share common cause.”

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But Church officials who spoke this weekend seem mainly to ignore the pope’s comments. Cardinal Tarcisio Bertone, the Vatican secretary of state, did not mention condoms. Instead, he focused on other behavior: “Educating people to avoid high-risk behavior, when based on solid moral principles, fully demonstrates its effectiveness and translates into greater openness toward those already affected by the virus.” Other officials spoke of the importance of abstinence and chastity before marriage and fidelity within marriage. In fact, at the conference the Vatican affirmed that married couples in which one member has HIV should practice abstinence within their marriage as well.

By not addressing condoms directly, the Vatican missed an opportunity for a realistic look at the role condoms play in preventing HIV and AIDS especially in Africa.  Some scientists are now questioning how much of the limited HIV-prevention resources should be invested in condom availability programs as opposed to programs that take other approaches.  Dr. Edward Green, the former director of the AIDS prevention research project at Harvard University, says that evidence shows what works in Africa, where the epidemic is largely driven by concurrent heterosexual partners, is male circumcision and partner reduction.  Green, who also spoke at the conference on Saturday, said in an interview: “I’m not anti-condom. They should be accessible, affordable, free. Just don’t bet the house and farm on it.” Green worries that there is little support for programs that advocate partner reduction especially among Western donors. 

Still, others suggest that partner reduction programs do not sufficiently acknowledge the reality of the lives of many women. Monsignor Kevin Dowling, who has been critical of the Vatican’s stance on condoms, was not invited to the Vatican’s conference. Dowling runs an HIV-prevention and care program in Rustenburg, South Africa and feels that condoms need to be a part of prevention—not for pregnancy but for disease. He says the women he sees are engaging in “survival sex,” exchanging sex for food and shelter because there are no available jobs: “What am I to say to her? That the only 100 percent sure way of ensuring that you will not become infected is to abstain from sex before marriage, and remain faithful to a single partner in a stable marriage for the rest of your life?’” Dowling said in an email. ‘Such “choices” are totally, but totally irrelevant to such people.”

Roundups Sexual Health

This Week in Sex: News From the HIV Epidemic

Martha Kempner

This week in sex: Scientists report the first case of HIV transmission to a patient adhering to PrEP protocols, two studies show a new vaginal ring can help women prevent HIV, and young people still aren't getting tested for the virus.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

With the death of Nancy Reagan, the 1980s AIDS crisis is back in the national spotlight. But, of course, HIV and AIDS are still ongoing problems that affect millions of people. This week in sex, we review scientists reporting the first case of HIV transmission to a patient adhering to PrEP protocols, two studies showing a new vaginal ring can help women prevent HIV, and evidence that young people still aren’t getting tested for the virus.

First Case of HIV Transmission While on Truvada

Last week, Canadian scientists reported on what they believe to be the first HIV infection in a patient who was following a PreP (Pre-Exposure Prophylaxis) regimen.

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PrEP is a method of HIV prevention. By taking a daily pill that contains two HIV medicines, sold under the name Truvada, individuals who are HIV-negative but considered to be at high risk of contracting the virus can prevent infection. Studies have found that PrEP is very effective—the Centers for Disease Control and Prevention estimates that people who take the medication every day can reduce their risk of infection by more than 90 percent from sex and by more than 70 percent from injection drug use. One study of men taking PrEP found no infections over a two-and-a-half-year period.

PrEP is less effective when not taken regularly, but the new case of reported PrEP failure involves a 43-year-old man who said that he took his medication daily. His pharmacy records back up that assertion. The man’s partner has HIV, but is on a drug regimen and has an undetectable viral load. The man did report other sexual encounters without condoms with casual partners in the weeks leading up to his diagnosis.

Dr. David Knox, the lead author of this case study, notes that it is difficult to know if a patient really did adhere to the drug regimen, but the evidence in this case suggests that he did. He concluded, “Failure of PrEP in this case was likely due to the transmission of a PrEP-resistant, multi-class resistant strain of HIV 1.”

Experts say, however, that they never expected PrEP to be infallible. As Richard Harrigan of the British Columbia Center for Excellence in HIV/AIDS told Pink News, “I certainly don’t think that this is a situation which calls for panic …. It is an example that demonstrates that PrEP can sometimes be ineffective in the face of drug resistant virus, in the same way that treatment itself can sometimes be ineffective in the face of drug resistant virus.”

Still, some fear that the new study will add to the ongoing debate and apathy that seem to surround PrEP. While some experts see it as a must-have prevention tool, others worry that it will encourage men who have sex with men to forgo using condoms and perhaps increase their risk for other sexually transmitted infections. Still, only 30,000 people in the United States are taking the drug—an estimated one-twentieth of those who could benefit from it.

A New Vaginal Ring Could Help Women Prevent HIV Infection

Researchers have announced promising results from two studies looking at new technology that could help women prevent HIV. The dapivirine ring, named after the drug it contains, was developed by the International Partnership for Microbicides. It looks like the contraceptive ring, Nuvaring, and is similarly inserted high up into the vagina for a month at a time. Instead of releasing hormones to prevent ovulation, however, this ring releases an antiretroviral drug to prevent HIV from reproducing in healthy cells. (A ring that could prevent both pregnancy and HIV is being developed.)

The two studies of the ring are being conducted in Africa. One study recruited about 2,600 women in Malawi, South Africa, Uganda, and Zimbabwe. It found that the ring reduced HIV infection by 27 percent overall and 61 percent for women over age 25. The other study, which is still underway, involves just under 2,000 women in seven sites in South Africa and Uganda. Early results suggest that the ring reduced infection by 31 percent overall when compared to the placebo.

Both studies found that the ring provided little protection to women ages 18-to-21. Researchers are now working to determine how adherence and other biological factors may have impacted such an outcome.

Young People Not Getting Tested for HIV

A study in the February issue of Pediatrics found that HIV testing rates among young people have not increased in the last decade. The researchers looked at data from the Youth Risk Behavior Survey (YRBS), which asks current high school students about sexual behaviors in addition to questions about drugs and alcohol, violence, nutrition, and personal safety (such as using bike helmets and seat belts). Specifically, the YRBS asks students if they’ve ever been tested for HIV.

Using YRBS data collected between 2005 and 2013, the researchers estimated that 22 percent of teens who had ever had sex had been tested for HIV. The percent who had received HIV tests was higher (34 percent) among those who reported four or more lifetime partners. Overall, male teens (17 percent) were less likely than their female peers (27 percent) to have been tested.

Researchers also looked at data from the Behavioral Risk Factor Surveillance System, which asks similar questions to young adults ages 18 to 24. Among people in this age group, between the years of 2011 to 2013, an average of 33 percent had ever been tested. This review of data also found that the percentage of young women who get tested for HIV has been decreasing in recent years—from 42.4 percent in 2011 to 39.5 percent in 2013.

The authors simply conclude, “HIV testing programs do not appear to be successfully reaching high school students and young adults.” They go on to suggest, “Multipronged testing strategies, including provider education, system-level interventions in clinical settings, adolescent-friendly testing services, and sexual health education will likely be needed to increase testing and reduce the percentage of adolescents and young adults living with HIV infection.”

News Sexual Health

New Study Has Hopeful Findings for HIV Prevention

Martha Kempner

A new study found that no one taking pre-exposure prophylaxis to prevent HIV became infected over the course of three years. But the rates of other STIs were still high.

A study published online in the journal Clinical Infectious Diseases reviewed the medical records of patients in the Kaiser Permanente system in San Francisco who had been referred for a pre-exposure prophylaxis (PrEP) evaluation between 2012 (when the drug became available) and early 2015. The majority of these patients (82 percent) decided to start taking PrEP to prevent HIV and in the almost three years of the study, not one of them contracted HIV.

These results are better than what would have been expected given clinical trials, and experts are excited that this new prevention method is working so well. But some are worried because condom use among these patients has dropped, and more than half of them were diagnosed with at least one sexually transmitted infection (STI) during the course of the study.

PrEP is a combination of two antiretroviral drugs—tenofovir and emtricitabine—used to treat people who have HIV, as Rewire has reported. When used daily by people who are HIV-negative, these drugs have been shown to prevent transmission of the virus. In May 2014, the Centers for Disease Control and Prevention (CDC) released guidelines that recommended HIV-negative individuals who are at “substantial risk for HIV infection” consider taking the drug.

The agency defined those at substantial risk as: anyone in an ongoing relationship with an HIV-infected partner; gay or bisexual men who are not in a mutually monogamous relationship with an HIV-negative partner and who have had sex without a condom or been diagnosed with a sexually transmitted infection within the past six months; heterosexual men or women who are not in a mutually monogamous relationship with an HIV-negative partner and do not regularly use condoms when having sex with partners known to be at risk for HIV (such as injecting drug users or bisexual male partners of unknown HIV status); or anyone who has injected illicit drugs and shared equipment or been in a treatment program for injection drug use within the past six months.

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The majority of the patients in the Kaiser Permanente study were men who had sex with men, though the study included three heterosexual women and one transgender man who was having sex with men.

The results were better than expected. The researchers followed 657 patients who took PrEP for a period of time that amounted to 388 person years. None of the patients contracted HIV.

“This is very reassuring data. It tells us the PrEP works even in high risk populations,” the study’s lead author, Dr. John Volk, told the New York Times.

Anthony Fauci, the director of the National Institute for Allergies and Infectious Diseases, agreed. “This shows the effectiveness of PrEP is really strikingly high,” he told the Times. “And this study takes it out of the realm of clinical trials and into the real world.”

The researchers noted that the study should allay fears that PrEP use would lead to less condom use and therefore more HIV. In the article, they write: “Our data suggest that fears about risk compensation resulting in increased HIV acquisition among PrEP users may be unfounded.”

Some public health experts are still concerned because while none of these patients contracted HIV, many of them contracted other STIs. A year after starting PrEP, 50 percent of patients had been diagnosed with an STI.

One-third of those patients had contracted chlamydia, 28 percent of patients had gonorrhea, and 5.5 percent had syphilis. Many of these infections were rectal.

Since there was no control group in this study, it is impossible to know whether these rates of STIs are higher than they would have been if the patients had not taken PrEP. Patients on PrEP are required to have frequent screenings for STIs. The high rates of STIs among this group, therefore, may reflect better testing rather than any real increase in the number of infections.

Still, there seems to be some behavior changes among patients on PrEP. Researchers surveyed 143 of the patients about their behavior. Seventy-four percent said the number of sexual partners they had did not change while on the drug, 15 percent said they had fewer partners, and 11 percent said they had more. Fifty-six percent said they did not change their condom use habits, 41 percent said they used condoms less often, and 3 percent said they used them more.

Though the patients enrolled in the study were engaging in high risk behaviors to begin with and some did not change their behavior because of PrEP, the STI rates among them are very concerning to some public health experts.

“We’re thrilled that there were no cases of HIV in the Kaiser PrEP study,” Deborah Arrindell, vice president of health policy at the American Sexual Health Association, told Rewire. “We’ve all been waiting for a study with these positive results. But there are thorns on the rose. Some participants did not follow the FDA guidelines to continue condom use. About half of those in the study contracted a sexually transmitted infection and that is worrisome.”

“More than one in four got gonorrhea—an infection for which we’re running out of treatment options,” Arrindell added. “That is cause for concern, even as we celebrate.​”