Yearly Archives: 2013

Taking HIV pre-exposure prophylaxis (PrEP) does not lead to increased levels of sexual risk behaviour among gay men, investigators from the United States report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Numbers of sexual partners fell, as did the proportion of men reporting unprotected anal sex.

“We found no evidence of risk compensation among at-risk MSM [men who have sex with men] initiating PrEP,” comment the authors. “Mean numbers of partners and the proportion of men reporting UAS [unprotected anal sex] decreased significantly from baseline during 24 months of follow-up.”

PrEP is an emerging HIV prevention technology. It involves HIV-negative individuals taking daily antiretroviral therapy to reduce their risk of infection with the virus. In 2010, results of the iPrEx trial involving gay and other MSM showed that daily PrEP with Truvada (FTC and tenofovir) reduced the risk of infection with HIV by 44% overall, with high efficacy seen in people with the best treatment adherence. Although the results of PrEP studies involving heterosexuals have been mixed, the United States Food and Drug Administration approved Truvada for use as PrEP by adults with a high risk of HIV infection.

However, there is concern in some quarters that use of PrEP may lead to increases in sexual risk behaviour. Mathematical models suggest that even modest increases in the proportion of gay men reporting unprotected sex could wipe out the beneficial effect of PrEP at a community level. However, the precise impact of PrEP on sexual risk taking is highly controversial.

Data gathered during a PrEP safety study allowed investigators to explore the impact of PrEP on the sexual risk behaviour of HIV-negative gay men with a high risk of infection with HIV.

A total of 400 men were recruited to the study between 2005 and 2007. All reported anal sex with another man in the preceding twelve months. The study was double blind and placebo controlled. Participants were randomised either to start treatment immediately or to wait for nine months. The men were interviewed at baseline and then every three months about their sexual risk behaviour and use of recreational and erectile dysfunction drugs. The study lasted 24 months.

At baseline, the men reported a mean of 7.25 sexual partners in the previous three months. This fell significantly during follow-up to a mean of 6 partners between months 3 and 9 and a mean of 5.71 partners between months 12 and 24 (p < 0.001). These declines were similar in the immediate- and delayed-treatment arms.

The mean number of reported HIV-positive partners or partners of an unknown status fell from 4.17 at baseline to 3.51 partners between months 3 and 9 and 3.37 partners between months 12 and 24 (p = 0.01). There was also a significant fall in the number of reported partners believed to be HIV negative.

Use of poppers (p < 0.001), erectile dysfunction drugs  (p < 0.001) and a higher perception of the efficacy of PrEP (p = 0.04) were all associated with reporting higher numbers of sexual partners during follow-up.

At the start of the study, 57% of men reported unprotected anal sex in the previous three months. The proportion fell to 48% between months 3 and 9  (p = 0.001) and to 52% between months 12 and 24 (p = 0.03).

The proportion of men reporting unprotected sex between months 3 and 9 was similar between the immediate- and delayed-treatment arms.

There was also a fall in the proportion of men reporting unprotected sex with an HIV-positive partner, from 29% at baseline to 21% between months 3 and 9 and 22% between months 12 and 24 (p < 0.001). Declines in unprotected sex with HIV-positive partners were seen in both the immediate- and delayed-treatment arms.

Factors associated with reporting unprotected sex during follow-up included younger age (p = 0.01), use of poppers (p = 0.02), erectile dysfunction treatments (p < 0.001) and methamphetamine (p < 0.001).

Participation in the study did not lead to an increase in the number of reported episodes of unprotected anal sex, which remained steady between months 3 and 9 and months 12 and 24 in both the immediate- and delayed-treatment arms.

There was a fall in reported episodes of unprotected sex with HIV-positive partners from two in the previous three-month period at baseline to 1.37 between months 12 and 24 (p = 0.05). This was the case for both the immediate- and delayed-treatment study arms.

In contrast, the number of episodes of unprotected anal sex with partners thought to be HIV negative increased between baseline and months 12 and 24 (2.75 Vs. 4; p = 0.01).

“These changes may represent a possible increase in seroadaptive practices, in which men preferentially have more episodes of UAS with assumed HIV-negative partners,” comment the authors.

They also note “men in this study received risk-reduction counseling, condoms and lubricants, regular HIV/STI testing, and linkage to prevention services…which may explain the observed risk reduction and could explain the observed risk declines and could mitigate any potential for risk compensation.”

Despite this, the investigators were encouraged by their results, which they believe “provide important information on changes in risk practices among MSM in the US initiating PrEP in a clinical trial setting”.

CLICK HERE to view study abstract.

“Get Yourself Tested” — New Data Shows 20 Million STIs Occur Each Year

Planned Parenthood, MTV, and the Kaiser Family Foundation Collaborate for STD Awareness Month

In March the UN Office on Drug Control released the International Standards on drug Use Prevention which can be found at:

http://www.unodc.org/unodc/en/prevention/prevention-standards.html.  Below is the introductory statement.

Prevention strategies based on scientific evidence working with families, schools, and communities can ensure that children and youth, especially the most marginalized and poor, grow and stay healthy and safe into adulthood and old age. For every dollar spent on prevention, at least ten can be saved in future health, social and crime costs.

These global International Standards summarize the currently available scientific evidence, describing interventions and policies that have been found to result in positive prevention outcomes and their characteristics. Concurrently, the global International Standards identify the major components and features of an effective national drug prevention system. It is our hope that the International Standards will assist policy makers worldwide to develop programmes, policies and systems that are a truly effective investment in the future of children, youth, families and communities. This work builds on and recognizes the work of many other organizations (e.g. EMCDDA, CCSA, CICAD, Mentor, NIDA, WHO) which have previously developed standards and guidelines on various aspects of drug prevention.

UNAIDS Executive Director Michel Sidibé joined health leaders from Africa and other international organizations to support a new push to accelerate progress against tuberculosis and HIV. The initiative was unveiled at a press briefing in Johannesburg, South Africa on 20 March and will be formerly launched on 21 March in Mbabane, Swaziland.

The initiative includes a package of new investments worth more than US $120 million which will be used to expedite progress against TB and HIV in the next 1000 days. The initiatvie will work with South African Development Community (SADC) countries to achieve the international targets of cutting deaths from TB and HIV-associated TB by half by 2015.

Mr Sidibé and other health leaders will sign the Swaziland Statement in Mbabane at tomorrow’s formal launch of the initiative.

In January, Dr John Williams hosted the 2nd Annual Conference “Health, Hope and Healing (H3): A National Conference on HIV among Black MSM and MSMW”, in collaboration with NAESM.

All the presentations from the conference are now available ONLINE

To find a specific talk, the agenda is HERE

What is NYHAAD?

National Youth HIV & AIDS Awareness Day (NYHAAD) is a HIV testing and treatment community mobilization initiative designed to raise awareness of HIV/AIDS prevention, care and treatment among youth ages 12-25 in the United States.

This campaign has four main objectives:

• Education: Distribute information about HIV/AIDS.
• Testing: Establish April 10th as an annual day for youth to get an HIV test.
• Involvement: Increase the number of youth involved in prevention campaigns and community mobilizing around HIV/AIDS.
• Treatment: Raise awareness of treatment services and information for HIV+ youth.

When is it recognized?

April 10, 2013 (This is also the first year of observance)

Why is an awareness day needed?

About 1 in 4 (26%) of all new HIV infections are among youth ages 13 to 24 years. About 60% of youth with HIV do not know they are infected and don’t receive treatment. This puts them at risk for sickness and early death. These youth can also unknowingly pass HIV to others.

Where are the events?

NYHAAD is a nationwide movement with organizers planning activities and events in thousands of locales. In Los Angeles, we are making a Call to Action utilizing social media for youth to share their stories and help raise awareness. But that’s just the beginning. You can plan your own individual events to observe the day as well.
What can I or my agency do? Support youth in telling their stories on Twitter, Facebook, Instagram, and YouTube. Please remember to review your agency’s social media policy before participating, if applicable. Sponsor a youth-led event that raises awareness in your community. Promote NYHAAD in your community through events and online activities.

Who are the organizers?

NYHAAD is a national initiative of Advocates for Youth. Contact Sulava Gautam-Adhikary, program coordinator, Advocates for Youth: msulava@advocatesforyouth.org.

Have questions about the campaign starter kit?

Contact Maria Sipin, health communications specialist, SYPP Center at Children’s Hospital Los Angeles: msipin@chla.usc.edu.

Download the NYHAAD Campaign Starter Kit: [Download not found]

Download the NYHAAD FAQ Sheet: [Download not found]

Download the Downtown Magnets High School Health and Wellness Fair Flyer: [Download not found]

By Warren Tong

From TheBodyPRO.com

A 26-month-old infant girl born in Mississippi has been functionally cured of HIV, according to results presented at CROI 2013 in Atlanta.

According to lead author Deborah Persaud, M.D., the infant was treated very early, within 31 hours of life, with zidovudine/lamivudine (AZT/3TC, Combivir) and nevirapine (Viramune). After a week, the nevirapine was switched out for lopinavir/ritonavir (Kaletra).

While HIV testing and prenatal treatment is standard for pregnant women in the U.S., the infant’s mother was not in care during her pregnancy.

The mother, who was unaware of her HIV status, was confirmed infected using standard rapid tests during labor and delivery. Within 30 hours, the baby was transferred to the University of Mississippi Medical Center, where Hannah Gay, M.D., administered two separate HIV tests: a nucleic acid test at 30 hours and a viral load test at 31 hours.

The test results didn’t come back until days later, but based on the mother’s prior lack of HIV care, Gay decided the risk of mother-to-child HIV transmission was too great, and made the highly unusual decision to start the child on a full antiretroviral regimen immediately.

Within a week, the nucleic acid test came back positive and the viral load test revealed the child had a viral load of about 20,000 copies/mL. Persaud noted that the two positive tests are the standard definition of HIV infection in a perinatally exposed child and therefore justified the decision to start the infant on HIV treatment.

Within a month, the baby’s viral load had lowered to undetectable levels. After 18 months of treatment, the mother decided to take the child off treatment. Despite this treatment discontinuation, the infant has continued to have an undetectable viral load through 26 months of age. Although HIV DNA fragments have been found in the baby’s blood in extremely small amounts, there has been no sign of any actively replicating virus.

“Plasma viral load, PBMC (peripheral blood mononuclear cells) DNA, and HIV-specific antibodies remained undetectable with standard clinical assays, confirming a state of functional HIV cure,” the researchers state in the study abstract. They theorize that very early treatment could have stopped the virus from forming reservoirs that cannot be eliminated with existing antiretrovirals; the existence of those reservoirs has thus far proven to be the primary roadblock to HIV eradication in chronically HIV-infected patients.

Dr. Persaud noted that this case appeared to be different from post-exposure prophylaxis (PEP) because the infant showed detectable levels of virus prior to treatment initiation, thus suggesting she was probably infected in the womb rather than during delivery.

For thoughtful analyses of the importance of this study and its significance for the HIV community, read this reaction article by Paul Sax, M.D., as well as this op-ed by Jim Merrell of the HIV Prevention Justice Alliance on the questions this story raises about the U.S. health care system.

The AIDS Healthcare Foundation, a longtime critic of the county’s health bureaucracy, has begun gathering signatures for a 2014 city ballot measure.

By Kate Linthicum and Anna Gorman, Los Angeles Times

March 10, 2013

A nonprofit group that delivers services to people with HIVand AIDS wants voters to force the city of Los Angeles to create its own health department, separate from the county.

The AIDS Healthcare Foundation, a longtime critic of the county’s health bureaucracy, wants the city to operate its own health agency rather than rely on the Los Angeles County Department of Public Health. The foundation has begun gathering signatures for a 2014 city ballot measure to do just that.

The county department is too big and does an abysmal job of disease control, foundation President Michael Weinstein said. A smaller, city-run agency would be more effective and accountable, said Weinstein, whose foundation won passage last year of a ballot measure requiring actors to wear condoms during shooting of pornographic movies.

City and county officials warn the proposal could reduce public health services for L.A. residents. City Administrative Officer Miguel Santana said the city simply doesn’t have the money, facilities or expertise to enforce public health laws.

“It would be very difficult, if not impossible, for the city to get in the business of healthcare,” said Santana, who noted that lawmakers are already struggling to maintain police, fire and other essential services in the face of looming budget deficits. “The city is simply not in a position to take this on.”

The city disbanded its health department in the 1960s. The county Department of Public Health works to reduce chronic illnesses, avoid infectious disease outbreaks and maintain the safety of food and water in the city and county. The agency is also in charge of emergency preparedness for the county’s 10 million residents.

Weinstein said a city department could be paid for by grants and fees. Currently, he said, “the money that would be going to the City of Los Angeles is being diverted to subsidize a bloated bureaucracy and wealthier cities.”

County health department Director Jonathan Fielding said officials are studying the ballot proposal. “We are concerned that it could result in duplication of services and reduction of public health protection for L.A. city residents,” he said in a statement.

The AIDS Healthcare Foundation is a longtime contractor with the county, but tensions between the entities have grown in recent years. Last fall, the county issued an audit criticizing the way the foundation tracked expenditures and said it overbilled the county by $1.7 million.

The foundation responded by filing a whistle-blower lawsuit alleging the county misused resources, wasted public funds and fabricated the audit. It took out ads in local newspapers that said, “LA County is a Danger to Your Health.”

Fielding said Friday that the health department “rejects the false characterizations” made by the foundation.

The conflict may come down to differing priorities, said UCLA Medical School professor Jeffrey Klausner. He said the AIDS group has been focused on condom use in adult film production, while the county public health department has much broader concerns.

“When folks don’t align with their goals, they seek every which way they can to achieve their aim,” Klausner said.

A city health department would presumably enforce the condom requirement within its borders. The City Council adopted a regulation last year, before the countywide vote, requiring condoms on porn shoots within the city’s borders.

Klausner said the proposal for a city health department is worth considering.

“Often we do see more success in public health areas when we can focus more locally,” said Klausner, the former deputy health officer for the San Francisco Department of Public Health.

Four California cities — Long Beach, Berkeley, Pasadena and Vernon — have their own public health departments.

Michael Johnson, support services manager with the health department in Long Beach, said the department works closely with its residents and other city agencies to determine which programs to prioritize. “We are very connected to our local community,” he said.

But, he said, creating a new department in Los Angeles would be a “significant undertaking.”

20th Conference on Retroviruses and Opportunistic Infections, March 3-6, 2013, Atlanta

Mark Mascolini

A lower CD4 count at HIV diagnosis raised the risk of death from non-AIDS cancer, non-AIDS infections, cardiovascular disease, and AIDS in a 5743-person analysis of the Austrian HIV Cohort Study [1]. A lower CD4 count when combination antiretroviral therapy (cART) began boosted the risk of death from non-AIDS cancers, non-AIDS infection, HBV/HCV-associated death, and AIDS.

The researchers divided observation time into three cART-era periods: 1997-2000, 2001-2004, and 2005-2011. They divided CD4 count at HIV diagnosis or cART initiation into four brackets: under 50, 50 to 199, 200 to 349, and 350 or higher. The researchers recorded deaths over the study period, checking for people lost to follow-up in death registries.

The study population included 4211 men (73%) and 1532 women. Nadir and latest CD4 counts averaged 227 and 510, and age at study entry averaged 36. Most cohort members acquired HIV heterosexually (38.2%) or during sex between men (34.1%). More than three quarters of study participants (79%) had ever taken cART, and 70.5% had taken cART for 6 months or more. Three quarters of study participants were Austrian, 12% came from other low HIV-prevalence countries, and 11% came from high-prevalence countries.

During follow-up, 876 people died, 311 (35.5%) from AIDS, 94 (10.7%) from non-AIDS cancers, 87 (9.9%) from HBV/HCV hepatitis, 79 (9.0%) from non-AIDS infections, and 48 (5.5%) from cardiovascular disease. More deaths were attributed to intoxication (6.5%) than to cardiovascular disease. Mortality fell from 3.61 deaths per 100 person-years in 1997-2000 to 2.42 in 2001-2004 and to 1.93 in 2005-2011. Median age at death rose in those three periods from 39.9 to 41.2 to 46.4, while median CD4 count before death climbed from 123 to 193 to 203.

From 1997-2000 to 2005-2011 mortality fell for AIDS (1.59 to 0.56 per 100 person-years), non-AIDS infections (0.25 to 0.20), HBV/HCV (0.38 to 0.16), and cardiovascular disease (0.28 to 0.10). But mortality from non-AIDS cancers climbed from 0.16 per 100 person-years in 1997-2000 to 0.21 in 2001-2004 and to 0.31 in 2005-2011. Mortality fell across the three study periods in every subgroup analyzed: age group, transmission mode, CD4s at diagnosis, CD4s at start of cART, and population in area of residence.

Compared with a CD4 count at or above 350 at HIV diagnosis or start of cART, lower CD4 counts at HIV diagnosis or cART start were associated with higher death rates at the following incidence rate ratios (IRR) and 95% confidence intervals (CI) in multivariable Poisson regression models:

Higher mortality by lower CD4 count at diagnosis compared with >350:
AIDS
200-349 CD4s: IRR 1.85 (1.04 to 3.29)
50-199 CD4s: IRR 5.75 (3.46 to 9.55)
Under 50 CD4s: IRR 16.05 (9.91 to 26.0)

Non-AIDS infection
50-199 CD4s: IRR 2.99 (1.23 to 7.28)
Under 50 CD4s: IRR 6.08 (2.43 to 15.24)

Non-AIDS malignancy
200-349 CD4s: IRR 2.39 (1.15 to 4.97)
50-199 CD4s: IRR 2.86 (1.29 to 6.35

Cardiovascular disease
50 to 199 CD4s: IRR 3.49 (1.36 to 8.96)

Higher mortality by lower CD4 count at start of cART compared with >350:
AIDS
50-199 CD4s: IRR 4.21 (2.75 to 6.43)
Under 50 CD4s: IRR 9.87 (6.40 to 15.23)

Non-AIDS infection
Under 50 CD4s: IRR 3.05 (1.41 to 6.60)

HBV/HCV
50-199 CD4s: IRR 2.46 (1.29 to 4.71)

Non-AIDS malignancy
50-199 CD4s: 2.16 (1.09 to 4.27)

The researchers warn that their statistical analysis is limited because it does not adjust for certain lifestyle factors, including smoking. It did adjust for gender, age, calendar year, duration of cART, HIV transmission category, and population of residence area. At the same time, the investigators cautioned that they may have underestimated mortality because of loss to follow-up of cohort members who left the country.

They proposed that “the association of a lower CD4 cell count at HIV diagnosis with increased mortality for most causes of death suggests an urgency to prevent individuals presenting late for care.”

Reference
1. Sturm G, Sarcletti M, Gog S, et al. A lower CD4 cell count at presentation is associated with increased mortality for most causes of death. 20th Conference on Retroviruses and Opportunistic Infections. March 3-6, 2013. Atlanta. Abstract 1044.  http://www.retroconference.org/2013b/PDFs/1044.pdf

By Jen Christensen, CNN

Tue March 5, 2013

(CNN) — The case of the first toddler ever to be “functionally cured” of HIV could have wide-ranging effects on the global fight to end the AIDS epidemic.

“If we can replicate this in other infants … this has huge implications for the burden of infection that’s occurring globally,” said Dr. Deborah Persaud, a pediatrician at the Johns Hopkins Children’s Center. Persaud is the lead author of a report on the toddler’s case that was presented at the 2013 Conference on Retroviruses and Opportunistic Infections in Atlanta on Monday.

“For the unfortunate ones who do get infected, if this can be replicated, this would offer real hope of clearing the virus.”

Some 1,000 infants are born with HIV every day, according to the latest estimates from the UNAIDS Global Report. That means some 330,000 children are living with the deadly virus. The majority of these infections are in the developing world.

The most common way children get HIV is through perinatal transmission — HIV transmission from an infected mother to a child while she is pregnant, giving birth or when she breast-feeds the child.

The number of infant infections in the United States has gone down some 90% since the mid-’90s, according to the Centers for Disease Control and Prevention; that’s in large part because pregnant women are routinely tested. When a mother is identified as being HIV positive, her doctor is then able to administer preventive interventions that will, in most cases, keep the virus in check.

In developing countries, infants born to mothers with HIV are not so lucky. There, mothers are less likely to be treated with antiretroviral drugs that would prevent transmission during pregnancy. In North Africa and the Middle East, for instance, 3% of pregnant women with HIV received antiretroviral medications, according to the U.N. report. Some 23% in West and Central Africa did. Testing is also less sophisticated in these areas.

The unidentified Mississippi woman in this case had no prenatal care and was not diagnosed as HIV positive until just before she delivered the baby. That’s why Dr. Hannah Gay, an associate professor of pediatrics at the University of Mississippi Medical Center, administered the drugs within 30 hours after the baby was born.

Typically, a baby born to a woman with HIV would be given two drugs as a prophylactic measure. Gay said her standard is to use a three-drug regimen to treat an infection. She did this on the Mississippi infant without waiting for test results to confirm the baby was infected with HIV.

Gay thinks the timing may be key, that the timing may deserve “more emphasis than the particular drugs or number of drugs used.

“We are hoping that future studies will show that very early institution of effective therapy will result in this same outcome consistently,” she said.

Doctors will try to replicate the success of her case and see if aggressive treatment right after birth can “cure,” or if this is an anomaly.

“We are enthusiastic about the potential of this case, but it is one case and it needs to be replicated and confirmed through future studies and clinical trials,” said Dr. Meg Doherty, the World Health Organization’s Department of HIV/AIDS coordinator of treatment and care. “We will not be changing any of our current guidance in this case, but we will continue to watch for new information and provide updates to our prevention of mother to child transmission (PMTCT) and early infant diagnosis guidance as necessary.”

Antiretroviral medications are pricey for people in the developing world, but treating a child for a year or two with these drugs would be a lot cheaper than paying for a lifetime of treatment after infection.

Persaud is optimistic. If the result of this case can be repeated, she believes this discovery could make a huge difference internationally.

“In resource-limited settings, this kind of treatment would not be a stretch. We know how to do this and we have the infrastructure in place to deliver this kind of care.”