Research Shows Neighborhoods Where AIDS Treatments Lag
New Epidemic - Hepatitis C Infection In HIV-infected Men
New Life-Saver for HIV Patients: Transplants
Bold New Strategy to Stop AIDS
November/December Positively Aware Available Now
Research Shows Neighborhoods Where AIDS Treatments Lag
The San Francisco health department has a map. A light shade of blue covers most neighborhoods. A slightly darker one covers the Castro, the center of the city’s gay culture. A dark stain covers Potrero Hill and Bayview. It shows where the sickest AIDS patients live. Many are untreated. The map is the product of a groundbreaking effort to identify where care should be focused.
According to a New York Times article on November 5, the research combines medical records and epidemiological tools to show the intensity of the illness, measured by an individual’s viral load. The goal is to determine where treatment and prevention efforts should be focused.
Dr. Grant Colfax, director of HIV prevention and research in the Public Health Department, calls San Francisco’s mapping of the viral loads measured from 2005 through 2007 “a thermometer.”
“We’re taking an individual marker and making it a marker for community health,” Dr. Colfax said.
“HIV is fully treatable and preventable,” said Dr. Julio Montaner, president of the International AIDS Society and head of the division of AIDS at the University of British Columbia. “We have not been able to fully control HIV in developed areas of the world to the extent our knowledge would allow.”
The mapping in San Francisco is “the next step in tracking the epidemic,” said Michael Cloutier, chief executive of the San Francisco AIDS Foundation. Dr. Colfax, the city’s senior investigator, agreed, saying: “If any place is able to reduce infections by treating people effectively, San Francisco should have the best chance. We’re hoping it will be a model.”
The city’s decisions on how to act on the new information will be controversial, all involved agree. Officials must decide whether to shift services, create pocketed marketing campaigns, or go directly to the individuals with the highest viral load and offer them appropriate care. But going to individuals could feel like “a police state” and cause some to run away, Dr. Montaner said. Dr. Colfax said, “You have to balance confidentiality with the fact that nobody in San Francisco should be walking around with a viral load of 100,000.”
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New Epidemic - Hepatitis C Infection In HIV-infected Men
Researchers in New York City are reporting their work uncovering a new epidemic of hepatitis C virus (HCV) infection among men who have sex with men (MSM) who are HIV-positive. It had been previously reported that unusually rapid fibrosis progression due to new HCV in HIV-positive MSM was found and now those findings have expanded to demonstrate that sexual transmission, rather than injection drug use, is the route of infection. Treatment is highly successful if started early in the course of infection, however, researchers report ominous news about liver disease progression. "This epidemic represents a new clinical syndrome for HCV infection that turns much of our knowledge on its ear: a new risk group becoming infected through a previously rare route of transmission, resulting in unprecedented progression of liver fibrosis," said Daniel Fierer, M.D., principal investigator on this study.
In an analysis of 21 HCV-infected patients matched with uninfected controls, unprotected receptive anal and oral sex were significantly associated with new HCV infection. Neither current nor prior injection drug use was associated with HCV infection. In addition, treatment with pegylated interferon and ribavirin, initiated within six months of diagnosis, was completed in 16 patients with genotype 1 HCV infection; 12 (75%) achieved sustained viral response (SVR), compared to the 15-30% SVR rate expected. Of significant concern, however, 30 patients underwent liver biopsy during the early infection period and 23 (77%) already had moderate fibrosis, making early curative treatment even more important to prevent further progression of liver fibrosis.
Because of these findings, study authors recommend routine screening for acute HCV for all HIV-positive MSM, using a simple and inexpensive algorithm of ALT measurement every three months and HCV antibody measurement every six to 12 months. "Changing the perception and behavior of physicians and patients is difficult," said Dr. Fierer, "One of the main barriers to early detection is the lack of recognition by physicians and patients alike that HIV-infected MSM are at risk for HCV infection. This lack of perception of the problem results in lack of screening of HIV-infected MSM and therefore lack of timely diagnosis and treatment."
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New Life-Saver for HIV Patients: Transplants
HIV infection is no longer an automatic reason for denying organ transplantation to patients who are otherwise candidates for the surgery. Since 1989, more than 500 transplants have been performed in patients known to have HIV, according to the United Network for Organ Sharing, the Richmond, Va.-based organization that manages the country's transplant system.
“Patients with HIV who meet the transplant criteria should be considered for transplant,” said Dr. Tony D'Alessandro, liver transplant director at the University of Wisconsin Hospital. Advances in medical care and fading stigma against HIV have helped make organ transplantation among HIV patients more commonplace.
According to a report by the Centers for Disease Control and Prevention (CDC), a person diagnosed with HIV in 2005 could expect to live another 23 years, up from 11 years in 1996. The increase in longevity is, in large part, the result of advances in antiretroviral therapy and disciplined management of HIV infection, doctors say.
In addition, doctors no longer believe the immunosuppressants that transplant recipients must take to prevent organ rejection are too dangerous for HIV patients. Recent research suggests that if an HIV infection is well managed, the addition of immunosuppressants appears to have no negative effects.
Most organ transplants in HIV-positive people have been done during the past five years, and virtually all were kidney or liver procedures. Dr. Peter Stock of the University of California-San Francisco, leads a National Institutes of Health study of some 275 HIV-positive transplant patients around the country. About 94% of kidney transplant patients in the study were still alive three years after the surgery. Some 83% had functioning kidneys at that time, while some had to return to dialysis. These outcomes are comparable to those for patients without HIV, Stock said. HIV infection does appear to produce poorer outcomes in liver transplant patients, particularly if the HIV-positive patient also has hepatitis C. Outcomes for HIV-positive patients with hepatitis B appear to be comparable to those of HIV-negative transplant patients.discuss this news brief in our discussion forum
Bold New Strategy to Stop AIDS
According to a report in the New York Times, “Federal health officials are preparing a plan to study a bold new strategy to stop the spread of the AIDS virus: routinely testing virtually every adult in a community, and promptly treating those found to be infected.
The strategy is called ‘test and treat,’ and officials say the two sites for the three-year study will be the District of Columbia and the Bronx — locales with some of the nation’s highest rates of infection with human immunodeficiency virus (HIV).”
The goal is not to measure whether “test and treat” actually works to slow an epidemic, but whether such a strategy can even be carried out, given the many barriers to being tested and getting medical care. Dr. Shannon L. Hader, director of the HIV/AIDS administration at this city’s Department of Health observed that in the progression from infection to treatment, “we lose people at every single step.” As many as 5% of the adults in the District of Columbia are infected — a rate Dr. Hader says is comparable with those in West Africa — and one-third to one-half do not even know they have the virus. The Centers for Disease Control and Prevention (CDC) reports that nationwide, 20% to 25% of people who are HIV-positive do not know their status.
Even when infection is diagnosed, “getting people from the field to the doctor is the hardest component,” said Angela Fulwood Wood, deputy director of Family and Medical Counseling Service, an agency that operates a mobile HIV testing clinic. Often, she added, someone who has just tested positive “can walk off that day and decide, ‘I’m going to pretend that never happened.’ ”
Researchers planning the study have been meeting with hospital and health officials in Washington and the Bronx to discuss making HIV testing a routine part of visits to doctors, clinics, and emergency rooms.
Last January, Dr. Reuben Granich and colleagues at the World Health Organization (WHO) published a study using mathematical models to predict the effects of universal testing and immediate treatment on a severe HIV epidemic among heterosexuals. They reported that such a policy, if combined with prevention efforts like promotion of condoms and male circumcision, could virtually eliminate transmission of the virus within 10 years.
Community testing programs are likely to attract people who suspect that they might have been exposed to or contracted HIV, but Ms Wood said the key to test and treat would be capturing those who did not volunteer for testing because they did not believe they could be infected —“people who are promiscuous at college, the partygoers, the young professionals who go to the club,” as she put it. She added, “Routine testing at either emergency rooms or physicians’ offices - I think that’s our biggest chance of really catching people earlier.”
So far, no city or country has come close to achieving universal testing for HIV and treatment for all those infected. But researchers and public health officials are eager to test the potential of such a strategy for stemming the epidemic.discuss this news brief in our discussion forum
November/December Positively Aware Available Now
The November/December issue of Positively Aware, "HIV Behind Bars: A Life Sentence", is now available in print, and will be online soon. The issue covers many aspects of HIV care in correctional facilities, including an overview from Dr. Chad Zawitz, as well as Editor Jeff Berry's experience with an inspiring group of South African grandmothers, and reports from the IAS Conference in Cape Town, South Africa.
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