HIVHope's International Newsletter Vol. III, No 3 - September 21, 2012
Please accept my apology for taking so long to get you this report on the International AIDS Conference. The past few months have been a very challenging time for my family and me. I am afraid I have been distracted from the ministry of HIVHope by the illness of our youngest daughter, Jennifer, whose life on earth came to an end on 5 September after many months of severe pain and extreme weight loss from cancer. We are now caring for her two children, ages 11 and 14, and adjusting to many new things in our lives. Please continue to pray for us as we walk with God through a number of major issues in our lives. We are so thankful for the wonderful way He has given us His amazing peace throughout this time (Phillipians 4:7).
Duane Crumb for the HIVHope Team
Special Report
Every two years the AIDS world gathers to share what has been learned and talk about ways to use that knowledge to move forward in attacking HIV disease. This July marked the third time I have been part of this event.
Being one of the almost 24,000 participants at this event is quite an experience. I met many wonderful people and hope to partner with some of them for future seminars around the world.
To be honest, I do not enjoy these meetings because they bring into such clear focus the extent to which those who make the decisions about HIV-related issues are committed to approaches HIVHope considers to be the wrong way to address the subject. Those organizations include the International AIDS Society, World Health Organization (WHO), UNAIDS, USAID, PEPFAR, and many others.
The theme of the conference this year was “Turning the Tide Together.” The atmosphere at the conference was more hopeful than I have ever seen with constant talk of “an AIDS free generation,” “a cure for HIV,” and even “the end of AIDS.” The way these things were being discussed suggested that these goals are within our grasp in the very near future. However, as I listened more deeply, two realities came into focus.
Our concern from this Conference is that a great deal of hope was offered. Of course hope is fundamental to what HIVHope is all about. However, false hope is worse than no hope at all. My concern is that much of the discussion at the 19th International AIDS Conference appears to be false hope at this point, especially for the vast majority of those living with or being newly infected with HIV.
The other concern is that the discussion centered around bio-medical approaches almost ignoring the behavioral approaches (other than condoms) that have been so effective and are, in our view, the most effective. The approaches emphasized included microbicides (still to be developed), vaccines (still years from being available), cures (may be possible in the future, but not for a long time), medical male circumcision (reducing the risk for the man by about 60%), and use of ARVs (still not available to everyone for a number of reasons). In the articles below there is more information on these.
Below are some articles with our comments about advances and ideas presented at the Conference.
In the News
HOPE ANTICIPATED
Breakthroughs Boost Optimism
USA Today (07.18.12) by Liz Szabo - A string of HIV prevention breakthroughs forms a hopeful backdrop to the 19th International AIDS Conference.
Among approaches cited by researchers as particularly significant:
PRE-EXPOSURE PROPHYLAXIS (PrEP) & TREATMENT AS PREVENTION (TasP)
Truvada Drug Trials Signal 'Turning Point' in AIDS Epidemic
USA Today (07.11.12) - Three new studies show the potential promise, as well as challenges, of using HIV drugs to prevent infection among healthy but high-risk patients. Two studies of African heterosexuals show pre-exposure prophylaxis (PrEP) reduced the rate of HIV infection by 62 percent to 75 percent, a rate similar to that seen in PrEP studies involving gay men. A third study focusing on African women ended early after showing no effect, mostly because fewer than 40 percent of participants took the pills as prescribed.
The studies overall bolster the idea of PrEP as one of the several powerful HIV prevention tools. “We’re at some sort of turning point in the AIDS epidemic. It’s not a single thing going on here. It’s the culmination of what’s happened for 30 years. Each of them is moving the political world to start thinking about an AIDS-free generation.”
A lingering challenge is finding ways to motivate uninfected patients to take the drugs properly. Researchers should investigate if the women in Africa stopped taking the drugs due to side effects or because they underestimated their risk of infection.
Treating HIV and Preventing Its Spread at the Same Time
Los Angeles Times (07.11.12) by Erin Loury - Getting the treatment-as-prevention (TasP) strategy to work as well in the real world as it has in trials may be difficult, experts suggest in a series of articles. Many barriers, including capacities and cost-effectiveness, could hamper the success of using antiretroviral therapy (ARVs) to stop new HIV infections, the experts wrote.
The field is split about whether it’s really the best thing and it’s going to stop transmission, or if it’s a small part of the puzzle, said an epidemiologist at Imperial College London and co-author of one of the articles.
Early treatment can have an impact, but it’s not going to eradicate HIV. In four places where testing and treatment linkage were already emphasized: British Columbia, San Francisco, France, and Australia, the best-case is Australia where treatment is freely available and about 70 percent of people with HIV are on it. Nonetheless, new HIV diagnoses there grew from 700 per year in 1999 to 1,000 annually in 2011.
People need to get tested regularly; start ARVs once they test HIV-positive; and adhere to ARVs for their whole lives to control the virus. Failure on any of these points reduces TasP’s potential.
HIVHope - These are two of the approaches that may be realistic to consider in wealthy countries. However, since the countries with the highest rates of infection are not yet able to make ARVs available to even close to all of those who are currently defined as needing them because of their reduced T-cell counts, how can anyone expect either PrEP or TasP to be effective in these places. The one barrier that was almost totally ignored at the conference was that so many places in the developing world have extreme shortages of doctors and nurses as well as the equipment necessary to provide proper follow up care to people who are put on ARVs. Until these shortages are resolved, talk about giving ARVs to people who are not yet infected or to those with high T-cell counts seems irresponsible as it would delay even further making the medications available to those whose immune systems are already significantly damaged by the virus.
Fewer Americans Suppressing HIV Virus, Study Finds
Baltimore Sun (07.22.12) by Meredith Cohn - According to a new study, many US HIV patients are not effectively controlling their infection, mostly due to a lack of drug adherence. The researchers looked at 100,000 blood tests from more than 30,000 patients over a decade. They found 72 percent were controlling their viral loads well, which was lower than the 87 percent previously found. Still, these numbers are significantly better than 2001, when only about 45 percent had well-controlled viral loads.
The researchers pointed to concerns of drug resistance and putting others at risk, An individual who misses one day’s worth of drugs is at risk of becoming resistant. Also, when you consider that over a large population, that’s how people spread the virus and they may be spreading the resistant kind, it’s a dangerous spiral.
Most people can now take one daily, multi-drug pill. However, if they become resistant to one of the drugs, they must take different medications in multiple pills, causing potential drug adherence problems. More efforts are needed to ensure drug adherence. The researchers plan additional research.
The study may increase concerns about using an antiretroviral drug for prevention among HIV-negative people, despite FDA’s recent approval for that purpose. We’ve made progress, but being able to take a pill every day is a lot harder than previously thought.
Most HIV-Positive Americans Lack Regular Care
Wall Street Journal (07.27.12) by Betsy McKay, Health blog - Only 25 percent of Americans with HIV have their virus under control, according to a CDC report released at the 19th International AIDS Conference.
Among African Americans with HIV, 81 percent have been diagnosed; 34 percent are retained in care; 29 percent have been prescribed antiretroviral therapy; and 21 percent are virally suppressed, CDC reported. Among Americans ages 25-34 who have HIV, 72 percent have been diagnosed; but only 28 percent receive regular care and 15 percent are virally suppressed.
Many other countries are doing this better than the US.
HIVHope - If there is any country in the world where you would expect that people living with HIV would be receiving adequate treatment and where ARVs would be effective in strategies like PrEP or TasP, it would be the United States. However, these articles highlight the problems being experienced even where the resources are available. Neither of these strategies can be effective just by making ARVs available. They depend on the medications being highly successful in dramatically reducing viral loads. If they are not having that impact in the US, what are the chances of doing so in the developing world?
HIV Drug Resistance Creeps Higher
Agence France Presse (07.18.12) - HIV drug resistance in low- and middle-income nations stood at 6.8 percent in 2010, the World Health Organization in its first-ever report on the issue. According to the WHO AIDS chief, “That is a level we sort of expected. It is not dramatic but we clearly need to look very carefully on how this would evolve further.” WHO did not recommend a change in treatment guidelines based on the study.
Drug resistance can occur when HIV mutates naturally, when treatment is interrupted, or when patients take medications incorrectly or irregularly. Approximately 8 million people in low- and middle-income countries received antiretroviral drugs last year, up 20 percent from 2010, according to a separate UNAIDS report. High-income countries have higher rates of resistance, from 8 percent to 14 percent. Many of these nations launched wide scale treatment programs years ago, often using single- or dual-drug therapies, which can encourage resistance. However, these higher rates have largely leveled off or decreased over time.
In 12 of the low- and middle-income countries in the WHO study, health care facilities lost contact with up to 38 percent of people who began treatment. When people interrupt or stop treatment, this not only means that they are themselves more likely to become sick, it also increases the likelihood that drug resistance will emerge and the resistant virus could be transmitted to others.
HIVHope - This article focuses on another concern with giving ARVs to people for TasP or PrEP. There is evidence that people who have never experienced significant sickness related to HIV infection do not realize how important their medication is. Thus, they are not as likely to faithfully take the ARVs for their lifetime. This has a serious potential for increasing the pool of people with resistant strains of HIV that will not respond to treatment and can be transmitted to others for whom the medications will not be effective.
AIDS FREE GENERATION
AIDS-Free Generation Within Reach Scientifically
USA Today (07.23.12) Liz Szabo - Science is showing the way to the world’s first AIDS-free generation in decades, a senior US health official said on the first day of the 19th International AIDS Conference in Washington. There is no excuse, scientifically, to say we cannot do it. What we need now is the political and organizational will to implement what science has given us.
The science behind the early initiation of treatment for people with HIV has been slam-dunk, out of the ballpark. Those whose viral levels are successfully controlled by treatment are virtually not infectious, research has shown. That suggests getting treatment to more people with HIV could be a powerful HIV prevention tool.
Some 20 percent of people with HIV do not know they have the virus, and most new infections are spread by the undiagnosed, he said. Seek, test, treat and retain is now the mantra for AIDS advocates. Changing the course of HIV/AIDS is not going to happen spontaneously. It’s going to require purpose and commitment.
HIVHope - Yes, it is going to require a lot of work to get us to an AIDS free generation. Please forgive us if we are somewhat cynical but we are concerned that the extremely hopeful messages at this Conference may have been designed, at least in part, as a strategy to get more funding for HIV research and programs in the current difficult world economy. There are serious doubts that the funds already available are being invested wisely on strategies that will be truly effective.
CURE & VACCINE
Scientists Urge Fresh Push for AIDS Cure
Agence France Presse (07.19.12) by Kerry Sheridan - International experts called for a renewed effort to cure AIDS, publishing a seven-step scientific strategy and introducing it at a press conference in Washington at the 19th International AIDS Conference. The strategy focuses on key issues including the reservoirs where HIV hides inside the body, and the few people who seem to have some natural resistance to the virus. The approaches being investigated - including gene therapy, immune treatments, and vaccines - would likely be most effective in combination with each other and antiretroviral therapy (ARVs).
It is estimated that for every HIV-infected person who starts antiretroviral therapy, two individuals are newly infected with HIV; this is clearly unsustainable. The science has been telling us for some time now that achieving a cure for HIV infection could be a realistic possibility. “The time is right to take the opportunity to try and develop an HIV cure. However, the search for a cure should not be funded by cutting current prevention and treatment efforts.
HIVHope - Many of you have heard us say that we do not expect there to be a cure for HIV because medicine has never been able to cure any virus. You have also heard us say that we pray that we are wrong and that a cure will be found. This conference offered the most hopeful messages about the potential for a cure that we have ever heard. Let’s pray they are successful while continuing to focus our efforts on motivating people to make life-choices that will keep them free of infection.
Scientists Making Progress on AIDS Vaccine, but Slowly
USA Today (07.26.12) by Liz Szabo - At the 19th International AIDS Conference the discovery was reported of a series of “Achilles heels” on the surface of HIV - developments that have reignited the search for an AIDS vaccine. We know the face of the enemy now. We have some real clues about how to approach the problem.
There are several key challenges that have made developing a vaccine so difficult. Because HIV is a retrovirus it does not simply infect the body: It inserts itself into a cell’s genome. An HIV vaccine must totally prevent infection. Once infection occurs, the virus inserts into the genome, and the immune system can’t kill it. In addition, though the body tries to defend itself, it cannot keep up with rapid pace at which HIV mutates. To be effective, an HIV vaccine would have to stimulate the production of broadly neutralizing antibodies to attack the virus regardless of its mutations. Potential weak points have now been discovered on HIV that appear to stay the same, even as the virus mutates. These could become the targets for vaccines. Another issue is HIV’s ability to hide itself and confuse the immune system. This raises the risk that a vaccinated person’s body would produce the proper antibodies, but that these would be unrecognized by the immune system and marked for elimination.
HIVHope - This article very clearly describes some of the reasons vaccine research continues to be so frustrating and why the experts continue to say that it we are not close to having a vaccine that could bring this disease to an end. There is progress, but it is extremely slow.
CIRCUMCISION
Studies Back Circumcision, but Obstacles Remain
Washington Post (07.26.12) by David Brown - Three studies have shown that male circumcision can reduce female-to-male HIV infection by 60 percent, but barriers remain to the procedure’s adoption in Africa, where it would do the most good.
Circumcision itself is simple and getting simpler. Research shows nurses can perform it safely after three days of training, and it can be done assembly-line-style with devices requiring no scalpels or stitches. However, some countries forbid task-shifting from doctors to less-expensive medical workers.
In addition, many ethnic groups have cultural traditions against male circumcision and healing requires sexual abstinence for six weeks. Since circumcision is only partially protective, preventive measures - such as using condoms - are still necessary.
Circumcision efforts are increasing in 14 African nations, where international health agencies hope to reach 80 percent of males ages 15-49 by 2015, or 20 million men. Just 1.5 million circumcisions have been conducted in the five years since the World Health Organization recommended the procedure in countries hard-hit by AIDS.
HIVHope - Again there is great hope for slowing (but not stopping) the spread of HIV through circumcision. This article helps us understand some of the obstacles that remain.
WOMEN
AIDS Experts say Focus on Pregnant Women Not Enough
Associated Press (07.25.12) by Lauran Neergaard - Specialists told the 19th International AIDS Conference that efforts to address AIDS among females must expand beyond the current focus on pregnant women. These adolescent girls and young women, our sisters and daughters, represent an unfinished agenda in the AIDS response. Women account for half the world’s HIV infections, and teenage girls are at especially high risk in countries hit hardest by the virus.
A key global goal is stopping mother-to-child (MTC) HIV transmission, and the number of babies infected by this route has been dropping steadily for several years. The UN reported that 57 percent of HIV-positive women last year received drugs while pregnant and nursing to protect their babies. The drop, however, has not been happening rapidly enough to meet the goal of virtually eliminating MTC infections by 2015. Few nations continue providing mothers with AIDS drugs after their babies are weaned, unless the woman’s condition worsens or she becomes pregnant again.
New World Health Organization guidelines recommend starting lifelong treatment for all pregnant women. Malawi is the first low-income nation to adopt this strategy which is also under consideration by Botswana, Rwanda, South Africa, and Zambia.
Growing International Acceptance of Option B+Management Sciences for Health (MSH), July 31, 2012 – As the international community gathered for the XIX International AIDS Conference, HIV & AIDS experts and key organizations voiced their support for a new approach to preventing mother-to-child transmission of HIV: Option B+. Option B+ calls for antiretroviral therapy (ART) for life for all HIV-positive pregnant women, regardless of CD4 levels.
The government of Malawi adapted the World Health Organization (WHO) guidelines on preventing mother-to-child transmission to the needs of Malawi. Current WHO guidelines (2010) distinguish between treatment and prevention (known as “prophylaxis”) and rely on accurate CD4 counts to determine ARV regimens.
Option B+ puts women and children first, and will likely be cost-effective for countries, like Malawi, in the long-term. In April, 2012, the World Health Organization (WHO) released a programmatic update saying, Now a new, third option (Option B+) proposes further evolution—not only providing the same triple ARV drugs to all HIV-infected pregnant women beginning in the antenatal clinic setting but also continuing this therapy for all of these women for life. Important advantages of Option B+ include: further simplification of regimen and service delivery and harmonization with ART programmes, protection against mother-to-child transmission in future pregnancies, a continuing prevention benefit against sexual transmission to serodiscordant partners, and avoiding stopping and starting of ARV drugs.
HIVHope - The idea of Option B+ is based on the same research that is driving the push for TasP and other approaches including one we have discussed in this newsletter in the past known as Test and Treat (TnT). You can expect to see a lot more about this idea in the coming months as more countries attempt to implement it. The question remains to be how this option can be implemented where there are not enough medical personnel to prescribe and follow treatment without B+. How is this dramatically increased demand going to be met.
INNOVATIVE IDEAS
Mobile Phones Help Bolster Uganda's Fight Against HIV
Agence France Presse (07.25.12) - A program that sends daily text message medication reminders to around 400 HIV patients in Kampala’s suburbs is part of a broad effort to utilize mobile technology in Uganda’s fight against AIDS. Twice-daily antiretrovirals require a minimum adherence rate of about 95 percent to be of greatest benefit to HIV/AIDS patients. Participants’ adherence rose from 75 percent to over 90 percent with this program.
Mobile phones are now so commonly used, especially among the youth, that it was time to repackage the information. In Uganda, mobile phones are used for everyday tasks like paying bills and sending money to rural relatives. Forty percent of the country’s population subscribe to a mobile phone service.
HIVHope - This seems like a wonderful way to increase the number of people taking ARVs properly. Perhaps you can put it into practice where you are.
Using Community Grapevine to Prevent Mother-to-Child Transmission
Inter Press Service (08.03.12) by Anne Mireille Nzouankeu - While the methods for preventing mother-to-child transmission (PMTCT) of HIV are well-known and highly effective, the process begins with an HIV test. And according to March data from the National Committee for the Fight Against AIDS, roughly one in five Cameroonian women who attend prenatal checkups refuse such testing. This June, UNICEF’s Cameroon office published figures showing the HIV rate among pregnant women in Cameroon is 7.6 percent. Nearly two-thirds of pregnant women do not receive prenatal care, UNICEF said. Further, many women go to private clinics or small birth centers in poor areas rather than public health centers where PMTCT is more routinely offered.
Organizations like No Limit For Women work to combat these challenges by educating women in the community about PMTCT. “We try to reach as many women as possible by taking part in meetings of various women’s associations. We urge these women to go to public hospitals and stay in touch with them by means of home visits.” Women who know they have HIV and want to have children but have concerns also are a target. “The plan is to create at least one community support group in each of Cameroon’s 179 health districts.” “This is already under way in some districts, but it is not yet in effect everywhere.”
HIVHope - Here is another effective strategy you may be able to adapt for use in your setting. Clearly, the more pregnant women who are tested, the fewer babies will be born with HIV. That is a very worthy goal!
Nurse-Centered HIV Care as Effective as Doctor's Care
Nursing Times (08.15.12) UK Press Association - A new study carried out in South Africa suggests that nurse-centered care of patients with HIV can be as effective as doctor-provided care, and it offers some particular benefits.
Researchers coordinated with several universities on the project — a two-year randomized controlled trial involving 15,000 patients in Free State, South Africa. The study marked the first time scientists have investigated doctor-to-nurse task-shifting on such a large scale. The results indicated a number of benefits for patients in nurse-centered care. These included significantly improved TB detection, increased white blood-cell counts, weight gain and better treatment compliance. In addition: When nurses, rather than doctors, administered antiretrovirals, survival rates were not negatively affected.
The findings show that with very little extra training and support, nurses can deliver HIV care that is just as safe and effective as that provided by doctors.
HIVHope - This article deals with the only strategy we heard about at the Conference to deal with the lack of medical personnel required for proper care for those on ARVs. It seems to be an excellent idea. However, there are some problems. 1) Many countries do not allow this kind of task shifting. 2) There is already a critical shortage not only of doctors, but also of nurses. Thus, shifting tasks to the nurses does not solve the problem as there are so few nurses and they are already over worked.
FINAL STATEMENT ON LOLIONDO, TANZANIA
Popular herbal cure-all "ineffective"
DAR ES SALAAM, 2 August 2012 (PLUSNEWS) - A widely used concoction administered by Tanzanian herbalist Ambilikile Mwasapile is ineffective, the country's health minister, Hussein Mwinyi, has said. Mwasapile, a former Lutheran pastor who claims God revealed the treatment to him in a dream, has drawn hundreds of thousands to his home in Samunge village, Loliondo over the past 18 months.
Believers claim it can cure a variety of diseases, including diabetes, cancer, tuberculosis and HIV. At the peak of his popularity, he was seeing up to 2,000 patients per day, each paying 500 Tanzanian shillings (about US$0.32) for one cup of the liquid.
Mwinyi told parliament on 31 July that studies conducted over the past year found no discernible difference between people who used it and those who did not. "This led us to the conclusion that the herb is not potent and effective at all. There was no change in CD4 count, weight and general health after the herb was administered to the patients," he said.
Despite warnings, many HIV-positive people abandoned their life-prolonging antiretroviral treatment after taking Mwasapile's herbs. Residents in Arusha region, where Samunge is located, say Mwasapile's
popularity has waned, with few people seeking his treatment in recent weeks.
Many people have lost their lives after taking the cup at Samunge. It was useless. There are people who were on first-line ARVs, but after taking the cup and briefly abandoning ARVs, ended up moving to second-line [medication]. Failure to adhere to ARVs can lead to resistance, forcing health workers to
switch patients to more expensive second- and third-line drugs.
People sold their property and others borrowed heavily to obtain fare or hired vehicles and travelled to Samunge village braving bad weather including rain. They are now poor or heavily indebted, but still sick. Some are now dead.
HIVHope - We pray that this will convince people not to go to Loliondo for this “treatment” and will convince people not to trust others making similar claims.
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Please accept my apology for taking so long to get you this report on the International AIDS Conference. The past few months have been a very challenging time for my family and me. I am afraid I have been distracted from the ministry of HIVHope by the illness of our youngest daughter, Jennifer, whose life on earth came to an end on 5 September after many months of severe pain and extreme weight loss from cancer. We are now caring for her two children, ages 11 and 14, and adjusting to many new things in our lives. Please continue to pray for us as we walk with God through a number of major issues in our lives. We are so thankful for the wonderful way He has given us His amazing peace throughout this time (Phillipians 4:7).
Duane Crumb for the HIVHope Team
Special Report
Every two years the AIDS world gathers to share what has been learned and talk about ways to use that knowledge to move forward in attacking HIV disease. This July marked the third time I have been part of this event.
Being one of the almost 24,000 participants at this event is quite an experience. I met many wonderful people and hope to partner with some of them for future seminars around the world.
To be honest, I do not enjoy these meetings because they bring into such clear focus the extent to which those who make the decisions about HIV-related issues are committed to approaches HIVHope considers to be the wrong way to address the subject. Those organizations include the International AIDS Society, World Health Organization (WHO), UNAIDS, USAID, PEPFAR, and many others.
The theme of the conference this year was “Turning the Tide Together.” The atmosphere at the conference was more hopeful than I have ever seen with constant talk of “an AIDS free generation,” “a cure for HIV,” and even “the end of AIDS.” The way these things were being discussed suggested that these goals are within our grasp in the very near future. However, as I listened more deeply, two realities came into focus.
- Realization of these goals is still decades away, not something that can be accomplished in the immediate future.
- Many of the strategies being prompted may be realistic in wealthy countries of Europe and North America. But, they are still much further away for the areas of the world where more than two out of every three people living with the virus reside.
Our concern from this Conference is that a great deal of hope was offered. Of course hope is fundamental to what HIVHope is all about. However, false hope is worse than no hope at all. My concern is that much of the discussion at the 19th International AIDS Conference appears to be false hope at this point, especially for the vast majority of those living with or being newly infected with HIV.
The other concern is that the discussion centered around bio-medical approaches almost ignoring the behavioral approaches (other than condoms) that have been so effective and are, in our view, the most effective. The approaches emphasized included microbicides (still to be developed), vaccines (still years from being available), cures (may be possible in the future, but not for a long time), medical male circumcision (reducing the risk for the man by about 60%), and use of ARVs (still not available to everyone for a number of reasons). In the articles below there is more information on these.
Below are some articles with our comments about advances and ideas presented at the Conference.
In the News
HOPE ANTICIPATED
Breakthroughs Boost Optimism
USA Today (07.18.12) by Liz Szabo - A string of HIV prevention breakthroughs forms a hopeful backdrop to the 19th International AIDS Conference.
Among approaches cited by researchers as particularly significant:
- Treatment as prevention (TasP): Antiretroviral therapy helps people with HIV remain healthy and cuts their risk of transmitting the virus.
- Pre-exposure prophylaxis (PrEP): US regulators recently approved the first drug to help protect uninfected people at high risk of sexual HIV exposure. PrEP studies have found those who took the pills faithfully could dramatically reduce their infection risk.
- Test and treat (TnT): Boosting testing and the proportion of those infected who receive treatment not only helps people with HIV, viral levels in the community also are generally lower.
- Adult male circumcision: Groups in Africa are offering the procedure to men as a way to reduce their HIV risk.
- Microbicides: Results from studies of these experimental gels, to be applied by vaginally women before and after sex to lower their risk of contracting HIV, have shown mixed results so far.
- Vaccines: A vaccine trial in Thailand showed a 31 percent reduction in HIV infections - not enough for widespread use, but a signal that vaccines could be effective in the future.
PRE-EXPOSURE PROPHYLAXIS (PrEP) & TREATMENT AS PREVENTION (TasP)
Truvada Drug Trials Signal 'Turning Point' in AIDS Epidemic
USA Today (07.11.12) - Three new studies show the potential promise, as well as challenges, of using HIV drugs to prevent infection among healthy but high-risk patients. Two studies of African heterosexuals show pre-exposure prophylaxis (PrEP) reduced the rate of HIV infection by 62 percent to 75 percent, a rate similar to that seen in PrEP studies involving gay men. A third study focusing on African women ended early after showing no effect, mostly because fewer than 40 percent of participants took the pills as prescribed.
The studies overall bolster the idea of PrEP as one of the several powerful HIV prevention tools. “We’re at some sort of turning point in the AIDS epidemic. It’s not a single thing going on here. It’s the culmination of what’s happened for 30 years. Each of them is moving the political world to start thinking about an AIDS-free generation.”
A lingering challenge is finding ways to motivate uninfected patients to take the drugs properly. Researchers should investigate if the women in Africa stopped taking the drugs due to side effects or because they underestimated their risk of infection.
Treating HIV and Preventing Its Spread at the Same Time
Los Angeles Times (07.11.12) by Erin Loury - Getting the treatment-as-prevention (TasP) strategy to work as well in the real world as it has in trials may be difficult, experts suggest in a series of articles. Many barriers, including capacities and cost-effectiveness, could hamper the success of using antiretroviral therapy (ARVs) to stop new HIV infections, the experts wrote.
The field is split about whether it’s really the best thing and it’s going to stop transmission, or if it’s a small part of the puzzle, said an epidemiologist at Imperial College London and co-author of one of the articles.
Early treatment can have an impact, but it’s not going to eradicate HIV. In four places where testing and treatment linkage were already emphasized: British Columbia, San Francisco, France, and Australia, the best-case is Australia where treatment is freely available and about 70 percent of people with HIV are on it. Nonetheless, new HIV diagnoses there grew from 700 per year in 1999 to 1,000 annually in 2011.
People need to get tested regularly; start ARVs once they test HIV-positive; and adhere to ARVs for their whole lives to control the virus. Failure on any of these points reduces TasP’s potential.
HIVHope - These are two of the approaches that may be realistic to consider in wealthy countries. However, since the countries with the highest rates of infection are not yet able to make ARVs available to even close to all of those who are currently defined as needing them because of their reduced T-cell counts, how can anyone expect either PrEP or TasP to be effective in these places. The one barrier that was almost totally ignored at the conference was that so many places in the developing world have extreme shortages of doctors and nurses as well as the equipment necessary to provide proper follow up care to people who are put on ARVs. Until these shortages are resolved, talk about giving ARVs to people who are not yet infected or to those with high T-cell counts seems irresponsible as it would delay even further making the medications available to those whose immune systems are already significantly damaged by the virus.
Fewer Americans Suppressing HIV Virus, Study Finds
Baltimore Sun (07.22.12) by Meredith Cohn - According to a new study, many US HIV patients are not effectively controlling their infection, mostly due to a lack of drug adherence. The researchers looked at 100,000 blood tests from more than 30,000 patients over a decade. They found 72 percent were controlling their viral loads well, which was lower than the 87 percent previously found. Still, these numbers are significantly better than 2001, when only about 45 percent had well-controlled viral loads.
The researchers pointed to concerns of drug resistance and putting others at risk, An individual who misses one day’s worth of drugs is at risk of becoming resistant. Also, when you consider that over a large population, that’s how people spread the virus and they may be spreading the resistant kind, it’s a dangerous spiral.
Most people can now take one daily, multi-drug pill. However, if they become resistant to one of the drugs, they must take different medications in multiple pills, causing potential drug adherence problems. More efforts are needed to ensure drug adherence. The researchers plan additional research.
The study may increase concerns about using an antiretroviral drug for prevention among HIV-negative people, despite FDA’s recent approval for that purpose. We’ve made progress, but being able to take a pill every day is a lot harder than previously thought.
Most HIV-Positive Americans Lack Regular Care
Wall Street Journal (07.27.12) by Betsy McKay, Health blog - Only 25 percent of Americans with HIV have their virus under control, according to a CDC report released at the 19th International AIDS Conference.
Among African Americans with HIV, 81 percent have been diagnosed; 34 percent are retained in care; 29 percent have been prescribed antiretroviral therapy; and 21 percent are virally suppressed, CDC reported. Among Americans ages 25-34 who have HIV, 72 percent have been diagnosed; but only 28 percent receive regular care and 15 percent are virally suppressed.
Many other countries are doing this better than the US.
HIVHope - If there is any country in the world where you would expect that people living with HIV would be receiving adequate treatment and where ARVs would be effective in strategies like PrEP or TasP, it would be the United States. However, these articles highlight the problems being experienced even where the resources are available. Neither of these strategies can be effective just by making ARVs available. They depend on the medications being highly successful in dramatically reducing viral loads. If they are not having that impact in the US, what are the chances of doing so in the developing world?
HIV Drug Resistance Creeps Higher
Agence France Presse (07.18.12) - HIV drug resistance in low- and middle-income nations stood at 6.8 percent in 2010, the World Health Organization in its first-ever report on the issue. According to the WHO AIDS chief, “That is a level we sort of expected. It is not dramatic but we clearly need to look very carefully on how this would evolve further.” WHO did not recommend a change in treatment guidelines based on the study.
Drug resistance can occur when HIV mutates naturally, when treatment is interrupted, or when patients take medications incorrectly or irregularly. Approximately 8 million people in low- and middle-income countries received antiretroviral drugs last year, up 20 percent from 2010, according to a separate UNAIDS report. High-income countries have higher rates of resistance, from 8 percent to 14 percent. Many of these nations launched wide scale treatment programs years ago, often using single- or dual-drug therapies, which can encourage resistance. However, these higher rates have largely leveled off or decreased over time.
In 12 of the low- and middle-income countries in the WHO study, health care facilities lost contact with up to 38 percent of people who began treatment. When people interrupt or stop treatment, this not only means that they are themselves more likely to become sick, it also increases the likelihood that drug resistance will emerge and the resistant virus could be transmitted to others.
HIVHope - This article focuses on another concern with giving ARVs to people for TasP or PrEP. There is evidence that people who have never experienced significant sickness related to HIV infection do not realize how important their medication is. Thus, they are not as likely to faithfully take the ARVs for their lifetime. This has a serious potential for increasing the pool of people with resistant strains of HIV that will not respond to treatment and can be transmitted to others for whom the medications will not be effective.
AIDS FREE GENERATION
AIDS-Free Generation Within Reach Scientifically
USA Today (07.23.12) Liz Szabo - Science is showing the way to the world’s first AIDS-free generation in decades, a senior US health official said on the first day of the 19th International AIDS Conference in Washington. There is no excuse, scientifically, to say we cannot do it. What we need now is the political and organizational will to implement what science has given us.
The science behind the early initiation of treatment for people with HIV has been slam-dunk, out of the ballpark. Those whose viral levels are successfully controlled by treatment are virtually not infectious, research has shown. That suggests getting treatment to more people with HIV could be a powerful HIV prevention tool.
Some 20 percent of people with HIV do not know they have the virus, and most new infections are spread by the undiagnosed, he said. Seek, test, treat and retain is now the mantra for AIDS advocates. Changing the course of HIV/AIDS is not going to happen spontaneously. It’s going to require purpose and commitment.
HIVHope - Yes, it is going to require a lot of work to get us to an AIDS free generation. Please forgive us if we are somewhat cynical but we are concerned that the extremely hopeful messages at this Conference may have been designed, at least in part, as a strategy to get more funding for HIV research and programs in the current difficult world economy. There are serious doubts that the funds already available are being invested wisely on strategies that will be truly effective.
CURE & VACCINE
Scientists Urge Fresh Push for AIDS Cure
Agence France Presse (07.19.12) by Kerry Sheridan - International experts called for a renewed effort to cure AIDS, publishing a seven-step scientific strategy and introducing it at a press conference in Washington at the 19th International AIDS Conference. The strategy focuses on key issues including the reservoirs where HIV hides inside the body, and the few people who seem to have some natural resistance to the virus. The approaches being investigated - including gene therapy, immune treatments, and vaccines - would likely be most effective in combination with each other and antiretroviral therapy (ARVs).
It is estimated that for every HIV-infected person who starts antiretroviral therapy, two individuals are newly infected with HIV; this is clearly unsustainable. The science has been telling us for some time now that achieving a cure for HIV infection could be a realistic possibility. “The time is right to take the opportunity to try and develop an HIV cure. However, the search for a cure should not be funded by cutting current prevention and treatment efforts.
HIVHope - Many of you have heard us say that we do not expect there to be a cure for HIV because medicine has never been able to cure any virus. You have also heard us say that we pray that we are wrong and that a cure will be found. This conference offered the most hopeful messages about the potential for a cure that we have ever heard. Let’s pray they are successful while continuing to focus our efforts on motivating people to make life-choices that will keep them free of infection.
Scientists Making Progress on AIDS Vaccine, but Slowly
USA Today (07.26.12) by Liz Szabo - At the 19th International AIDS Conference the discovery was reported of a series of “Achilles heels” on the surface of HIV - developments that have reignited the search for an AIDS vaccine. We know the face of the enemy now. We have some real clues about how to approach the problem.
There are several key challenges that have made developing a vaccine so difficult. Because HIV is a retrovirus it does not simply infect the body: It inserts itself into a cell’s genome. An HIV vaccine must totally prevent infection. Once infection occurs, the virus inserts into the genome, and the immune system can’t kill it. In addition, though the body tries to defend itself, it cannot keep up with rapid pace at which HIV mutates. To be effective, an HIV vaccine would have to stimulate the production of broadly neutralizing antibodies to attack the virus regardless of its mutations. Potential weak points have now been discovered on HIV that appear to stay the same, even as the virus mutates. These could become the targets for vaccines. Another issue is HIV’s ability to hide itself and confuse the immune system. This raises the risk that a vaccinated person’s body would produce the proper antibodies, but that these would be unrecognized by the immune system and marked for elimination.
HIVHope - This article very clearly describes some of the reasons vaccine research continues to be so frustrating and why the experts continue to say that it we are not close to having a vaccine that could bring this disease to an end. There is progress, but it is extremely slow.
CIRCUMCISION
Studies Back Circumcision, but Obstacles Remain
Washington Post (07.26.12) by David Brown - Three studies have shown that male circumcision can reduce female-to-male HIV infection by 60 percent, but barriers remain to the procedure’s adoption in Africa, where it would do the most good.
Circumcision itself is simple and getting simpler. Research shows nurses can perform it safely after three days of training, and it can be done assembly-line-style with devices requiring no scalpels or stitches. However, some countries forbid task-shifting from doctors to less-expensive medical workers.
In addition, many ethnic groups have cultural traditions against male circumcision and healing requires sexual abstinence for six weeks. Since circumcision is only partially protective, preventive measures - such as using condoms - are still necessary.
Circumcision efforts are increasing in 14 African nations, where international health agencies hope to reach 80 percent of males ages 15-49 by 2015, or 20 million men. Just 1.5 million circumcisions have been conducted in the five years since the World Health Organization recommended the procedure in countries hard-hit by AIDS.
HIVHope - Again there is great hope for slowing (but not stopping) the spread of HIV through circumcision. This article helps us understand some of the obstacles that remain.
WOMEN
AIDS Experts say Focus on Pregnant Women Not Enough
Associated Press (07.25.12) by Lauran Neergaard - Specialists told the 19th International AIDS Conference that efforts to address AIDS among females must expand beyond the current focus on pregnant women. These adolescent girls and young women, our sisters and daughters, represent an unfinished agenda in the AIDS response. Women account for half the world’s HIV infections, and teenage girls are at especially high risk in countries hit hardest by the virus.
A key global goal is stopping mother-to-child (MTC) HIV transmission, and the number of babies infected by this route has been dropping steadily for several years. The UN reported that 57 percent of HIV-positive women last year received drugs while pregnant and nursing to protect their babies. The drop, however, has not been happening rapidly enough to meet the goal of virtually eliminating MTC infections by 2015. Few nations continue providing mothers with AIDS drugs after their babies are weaned, unless the woman’s condition worsens or she becomes pregnant again.
New World Health Organization guidelines recommend starting lifelong treatment for all pregnant women. Malawi is the first low-income nation to adopt this strategy which is also under consideration by Botswana, Rwanda, South Africa, and Zambia.
Growing International Acceptance of Option B+Management Sciences for Health (MSH), July 31, 2012 – As the international community gathered for the XIX International AIDS Conference, HIV & AIDS experts and key organizations voiced their support for a new approach to preventing mother-to-child transmission of HIV: Option B+. Option B+ calls for antiretroviral therapy (ART) for life for all HIV-positive pregnant women, regardless of CD4 levels.
The government of Malawi adapted the World Health Organization (WHO) guidelines on preventing mother-to-child transmission to the needs of Malawi. Current WHO guidelines (2010) distinguish between treatment and prevention (known as “prophylaxis”) and rely on accurate CD4 counts to determine ARV regimens.
Option B+ puts women and children first, and will likely be cost-effective for countries, like Malawi, in the long-term. In April, 2012, the World Health Organization (WHO) released a programmatic update saying, Now a new, third option (Option B+) proposes further evolution—not only providing the same triple ARV drugs to all HIV-infected pregnant women beginning in the antenatal clinic setting but also continuing this therapy for all of these women for life. Important advantages of Option B+ include: further simplification of regimen and service delivery and harmonization with ART programmes, protection against mother-to-child transmission in future pregnancies, a continuing prevention benefit against sexual transmission to serodiscordant partners, and avoiding stopping and starting of ARV drugs.
HIVHope - The idea of Option B+ is based on the same research that is driving the push for TasP and other approaches including one we have discussed in this newsletter in the past known as Test and Treat (TnT). You can expect to see a lot more about this idea in the coming months as more countries attempt to implement it. The question remains to be how this option can be implemented where there are not enough medical personnel to prescribe and follow treatment without B+. How is this dramatically increased demand going to be met.
INNOVATIVE IDEAS
Mobile Phones Help Bolster Uganda's Fight Against HIV
Agence France Presse (07.25.12) - A program that sends daily text message medication reminders to around 400 HIV patients in Kampala’s suburbs is part of a broad effort to utilize mobile technology in Uganda’s fight against AIDS. Twice-daily antiretrovirals require a minimum adherence rate of about 95 percent to be of greatest benefit to HIV/AIDS patients. Participants’ adherence rose from 75 percent to over 90 percent with this program.
Mobile phones are now so commonly used, especially among the youth, that it was time to repackage the information. In Uganda, mobile phones are used for everyday tasks like paying bills and sending money to rural relatives. Forty percent of the country’s population subscribe to a mobile phone service.
HIVHope - This seems like a wonderful way to increase the number of people taking ARVs properly. Perhaps you can put it into practice where you are.
Using Community Grapevine to Prevent Mother-to-Child Transmission
Inter Press Service (08.03.12) by Anne Mireille Nzouankeu - While the methods for preventing mother-to-child transmission (PMTCT) of HIV are well-known and highly effective, the process begins with an HIV test. And according to March data from the National Committee for the Fight Against AIDS, roughly one in five Cameroonian women who attend prenatal checkups refuse such testing. This June, UNICEF’s Cameroon office published figures showing the HIV rate among pregnant women in Cameroon is 7.6 percent. Nearly two-thirds of pregnant women do not receive prenatal care, UNICEF said. Further, many women go to private clinics or small birth centers in poor areas rather than public health centers where PMTCT is more routinely offered.
Organizations like No Limit For Women work to combat these challenges by educating women in the community about PMTCT. “We try to reach as many women as possible by taking part in meetings of various women’s associations. We urge these women to go to public hospitals and stay in touch with them by means of home visits.” Women who know they have HIV and want to have children but have concerns also are a target. “The plan is to create at least one community support group in each of Cameroon’s 179 health districts.” “This is already under way in some districts, but it is not yet in effect everywhere.”
HIVHope - Here is another effective strategy you may be able to adapt for use in your setting. Clearly, the more pregnant women who are tested, the fewer babies will be born with HIV. That is a very worthy goal!
Nurse-Centered HIV Care as Effective as Doctor's Care
Nursing Times (08.15.12) UK Press Association - A new study carried out in South Africa suggests that nurse-centered care of patients with HIV can be as effective as doctor-provided care, and it offers some particular benefits.
Researchers coordinated with several universities on the project — a two-year randomized controlled trial involving 15,000 patients in Free State, South Africa. The study marked the first time scientists have investigated doctor-to-nurse task-shifting on such a large scale. The results indicated a number of benefits for patients in nurse-centered care. These included significantly improved TB detection, increased white blood-cell counts, weight gain and better treatment compliance. In addition: When nurses, rather than doctors, administered antiretrovirals, survival rates were not negatively affected.
The findings show that with very little extra training and support, nurses can deliver HIV care that is just as safe and effective as that provided by doctors.
HIVHope - This article deals with the only strategy we heard about at the Conference to deal with the lack of medical personnel required for proper care for those on ARVs. It seems to be an excellent idea. However, there are some problems. 1) Many countries do not allow this kind of task shifting. 2) There is already a critical shortage not only of doctors, but also of nurses. Thus, shifting tasks to the nurses does not solve the problem as there are so few nurses and they are already over worked.
FINAL STATEMENT ON LOLIONDO, TANZANIA
Popular herbal cure-all "ineffective"
DAR ES SALAAM, 2 August 2012 (PLUSNEWS) - A widely used concoction administered by Tanzanian herbalist Ambilikile Mwasapile is ineffective, the country's health minister, Hussein Mwinyi, has said. Mwasapile, a former Lutheran pastor who claims God revealed the treatment to him in a dream, has drawn hundreds of thousands to his home in Samunge village, Loliondo over the past 18 months.
Believers claim it can cure a variety of diseases, including diabetes, cancer, tuberculosis and HIV. At the peak of his popularity, he was seeing up to 2,000 patients per day, each paying 500 Tanzanian shillings (about US$0.32) for one cup of the liquid.
Mwinyi told parliament on 31 July that studies conducted over the past year found no discernible difference between people who used it and those who did not. "This led us to the conclusion that the herb is not potent and effective at all. There was no change in CD4 count, weight and general health after the herb was administered to the patients," he said.
Despite warnings, many HIV-positive people abandoned their life-prolonging antiretroviral treatment after taking Mwasapile's herbs. Residents in Arusha region, where Samunge is located, say Mwasapile's
popularity has waned, with few people seeking his treatment in recent weeks.
Many people have lost their lives after taking the cup at Samunge. It was useless. There are people who were on first-line ARVs, but after taking the cup and briefly abandoning ARVs, ended up moving to second-line [medication]. Failure to adhere to ARVs can lead to resistance, forcing health workers to
switch patients to more expensive second- and third-line drugs.
People sold their property and others borrowed heavily to obtain fare or hired vehicles and travelled to Samunge village braving bad weather including rain. They are now poor or heavily indebted, but still sick. Some are now dead.
HIVHope - We pray that this will convince people not to go to Loliondo for this “treatment” and will convince people not to trust others making similar claims.
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