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Kaiser Daily HIV/AIDS Report [Aug 07, 2008]
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Fauci, Piot discuss progress in HIV/AIDS treatments, prevention
National Institute of Allergy and Infectious Diseases Director Anthony Fauci and UNAIDS Executive Director Peter Piot on Wednesday at the XVII International AIDS Conference in Mexico City discussed progress in HIV/AIDS treatments and prevention efforts and the future of HIV treatment, Bloomberg reports.
According to Fauci, HIV-positive people eventually might be able to stop taking drugs and live without symptoms if they are treated aggressively with newer antiretroviral drugs. Treating patients soon after they are contract HIV could protect the immune system and suppress their viral loads, allowing them to slowly stop taking the drugs.
Fauci said that he believes physicians will someday "be able to ... eradicate HIV microbiologically" in "some patients, not very many," and have a "functional cure" for others. He said such a possibility "will likely require aggressive drug regimens and rely on the timing of initiating therapy." A "cure will likely require early diagnosis and treatment," Fauci said, adding, "Studies need to be done in [the] next few years to determine if very aggressive therapy early on will allow us to get a functional cure." In addition, a vaccine that targets people with a specific genetic makeup could be available within 20 years, Fauci said. Fauci said that while research into an HIV vaccine is ongoing, researchers also are looking into using antiretrovirals to prevent HIV.
Piot said that the pharmaceutical industry needs to continue to invest in the development of new HIV treatments and look into the possibility of using existing antiretrovirals to prevent HIV transmission. "We have to make sure the drug development remains in step with the evolution of the virus and that industry continues to invest," Piot said, adding that there are "worrying signs that that isn't the case, and that is something we have to put on the table."
In addition, effective prevention methods that target men who have sex with men, commercial sex workers and injection drug users need to be scaled up to slow the spread of the virus, Piot said, adding that health workers also must learn how to target prevention messages more effectively. "No company will try to sell soap if they haven't done research for the community they are trying to sell to," Piot said, adding, "It would pay off if we could bring that experience from the business world to our amateur approaches" to HIV prevention campaigns (Pettypiece, Bloomberg, 8/6).
Efforts to fight HIV/AIDS not reaching enough children, health workers at conference say
Despite significant funding for HIV/AIDS treatment in the developing world and efforts to prevent mother-to-child transmission, the global response to the disease has "short-changed" children, health workers at the XVII International AIDS Conference in Mexico City said Wednesday during the conference's first plenary lecture on children, the New York Times reports. In the past five years, 1.5 million children have died of AIDS-related causes, and 15 million children have lost one or both parents to the disease, according to Michael Sidibe, a UNAIDS official. An estimated two million children younger than age 15 are HIV-positive.
Jim Yong Kim of Harvard University said that about 6% to 10% of children in need of antiretroviral drugs receive them, compared with 30% of adults (Altman, New York Times, 8/7). In addition, fewer than one in 10 infants in low- and middle-income countries were tested for HIV within two months of their birth, despite new evidence that early treatment significantly increases their chances of survival, South Africa's The Star reports (Green, The Star, 8/7).
Linda Richter, a psychologist in South Africa who delivered the lecture, said too little government and donor money reaches children living with HIV/AIDS. What money is allocated toward children with HIV/AIDS generally goes to consultants and overhead costs, according to Richter (New York Times, 8/7). Richter said HIV in children has increased eightfold in sub-Saharan Africa, where 90% of the world's HIV-positive children live. The increase is largely the result of MTCT, as many pregnant women did not know they were HIV-positive or did not have access to prevention services (The Star, 8/7). Too few pregnant women receive the antiretroviral drugs that could prevent transmission of HIV, Richter said.
Richter said that although the news media have often focused on the experience of AIDS orphans, "children orphaned by AIDS are, sadly, only the tip of the iceberg of HIV-affected children" (New York Times, 8/7). "It is the needs of all children, especially vulnerable children, not whether they meet the definition of orphan, that must be our primary focus," Richter said, adding, "The focus on orphans had individualized the challenge of care and support. It has framed the epidemic's impact on children as individuals rather than a national social problem and has separated assistance to children from efforts to support families and communities" (The Star, 8/7).
Richter, who said all children in communities severely affected by HIV/AIDS require psychological, nutritional and other support, added that treating children in HIV/AIDS programs would be more effective and efficient if money went directly to families and communities. She added that low-income people have shown that they make good decisions about obtaining food and other provisions and that financial barriers, including bus fare to treatment centers, often prevent women from taking their children for medical care.
A report released by the Joint Learning Initiative on Children and HIV/AIDS said that governments and donors should develop new approaches to help children most affected by the disease. Other speakers during the lecture said that children would be better served through a study of family dynamics. Lorraine Sherr of University College London said that more needs to be done to help families cope psychologically following the death of an HIV-positive family member (New York Times, 8/7).
U.N. goal of 'universal access' to antiretrovirals unlikely to be reached worldwide
The United Nations' goal of providing universal access to antiretroviral drugs by 2010 is unlikely to be reached by some countries, Michel Kazatchkine, executive director of the Global Fund To Fight AIDS, Tuberculosis and Malaria, and Peter Piot, executive director of UNAIDS, said on Wednesday at the XVII International AIDS Conference in Mexico City, AFP/Yahoo! News reports. The 2010 target was agreed to at a 2006 United Nations General Assembly meeting and later supported by the Group of Eight industrialized nations.
Kazatchkine and Piot said they believe U.N. members are still committed to the target, but they doubt the goal would be reached by every country. "2010 is 18 months from now. What we've seen is that in a number of countries, they've already reached their universal access targets, others not." According to Piot's spokesperson, some countries could achieve universal access in 2011 or 2012, which is in line with their national programs. Kazatchkine said, "When we look at global targets, none of us believes that it will be 100% everywhere," adding, "But if you look at individual countries, and if you look at the percent that have achieved universal coverage or (will) be close to universal coverage, there may be much more than you think of."
According to AFP/Yahoo! News, three million HIV-positive people have access to antiretrovirals as a result of a large scale-up in treatment access in the last two years, but only about one-third of the people who need drugs worldwide are receiving them. HIV/AIDS advocates "closely scrutinized" the G8's July 2008 statement on increased HIV/AIDS spending and last week's UNAIDS report on the state of the pandemic, AFP/Yahoo! News reports. Some advocates said they see a "weakening" of commitment to the 2010 target and a "dangerous slippage" to 2015, which is also the end date for the United Nations Millennium Development Goals on reversing the spread of HIV/AIDS, AFP Yahoo! News reports. Piot said the 2010 goal "has not changed whatsoever."
Costs of Universal Access
Kazatchkine and Piot also said that new ideas are needed for addressing the increasing cost of providing antiretroviral drugs to HIV-positive people who need them. According to estimates, universal access will cost $54 billion annually by 2015, a figure that could increase as people living with HIV/AIDS continue taking antiretrovirals for the rest of their lives.
Newspapers examine challenges in HIV prevention among MSM
Rising HIV prevalence among men who have sex with men, "[h]omophobia, biology and misplaced confidence that AIDS has become a treatable chronic illness are contributing to a disturbing flashback among scientists and activists" and concern among public health officials that many countries "appear to be repeating the early patterns of the epidemic," the Washington Post reports.
HIV/AIDS was labeled a "homosexual disease" when it first appeared in the 1980s, but then "an enormous grassroots movement ... sparked government action, and more significantly, effective prevention campaigns" among MSM, the Post reports. However, HIV infections among MSM have been increasing, particularly among communities where there is a stigma against homosexuality, according to the Post.
Michael Sidibe, assistant secretary general of the United Nations, said, "We have come full circle. In the beginning, gay men in places like San Francisco and New York proved we could do prevention. When we moved from that and started talking about the broad scope of the epidemic, suddenly men who have sex with men became marginalized."
"'Prevention fatigue,' confidence in new antiretroviral drugs, the use of methamphetamines and the arrival of a generation of young men who did not experience the ravages of the 1980s" is contributing to the situation, according to Richard Wolitski, acting director of CDC's HIV/AIDS prevention division. Wolitski added that HIV is "transmitted more easily via anal sex than vaginal sex."
Many MSM in the U.S. engage in "serosorting," where they try to calculate risk based on their own and their partner's HIV status, the Post reports. However, many men do not know they have HIV and can unknowingly spread the disease, Wolitski said.
"The same kinds of stigma and discrimination and institutionalized homophobia that failed gay men in America is now failing MSM in the rest of the world," Kevin Frost, CEO of the American Foundation for AIDS Research, said. Frost added that increased HIV incidence among MSM, in many cases, is "directly related to the institutionalization of homophobia" (Connolly, Washington Post, 8/7).
An AmfAR report released Monday at the XVII International AIDS Conference in Mexico City found MSM are at an increased risk of HIV. According to the report, despite a unanimous commitment that all U.N. member countries made in 2001 to monitor HIV among high-risk groups, 71% of countries said they did not have any information on the percentage of MSM contacted by HIV prevention groups. Of 128 countries, 44% failed to provide HIV data on MSM.
According to the report, Benin, Ghana, Jamaica, Kenya and Thailand are the countries with the highest reported HIV prevalence among MSM. Although data were scarce, the study found MSM were 33 times more likely to be living with HIV than the general population in Latin America, 18 times more likely in Asia and at least four times more likely in Africa (Kaiser Daily HIV/AIDS Report, 8/6).
Sexual activity between men is criminalized in 85 countries and is punishable by death in seven countries and by imprisonment in 76 countries, according to the International Lesbian and Gay Association.
Craig McClure, executive director of the International AIDS Society, said, "It's difficult to provide services to men who have sex with men in countries where they don't acknowledge they exist" (Washington Post, 8/7).
Post reporter Ceci Connolly on Thursday will discuss her series on HIV/AIDS along the U.S.-Mexico border and her coverage of the XVII International AIDS Conference (Washington Post Live Discussion, 8/7). A resource page on HIV/AIDS and the XVII International AIDS Conference also is available online from the Post.
Globe and Mail: The HIV community has "failed to bring down the incidence of HIV/AIDS in MSM because we have not tried," Jorge Saavedra, director of Mexico's national HIV/AIDS program CENSIDA, said at the AIDS conference. McClure added that providing human rights protections for MSM and addressing the stigma of same-sex relationships are necessary to slow the spread of HIV. UNAIDS Executive Director Peter Piot at the AIDS conference called on countries to revise policies that criminalize same-sex activity, saying that the laws discourage MSM from seeking HIV testing and treatment. "Homophobia kills. We must kill homophobia," Piot said (Picard, Globe and Mail, 8/7).
New York Times: The Times on Thursday examined men who have sex with men in Mexico and Latin America. According to the Times, "Because machismo is pronounced in Mexico and homosexuality is far from accepted, social conditions in the country and in other parts of Latin America force much sexual behavior into the shadows. That increases the challenges that AIDS experts say they face in combating the risky sexual practices that fuel the disease." The Times reports that MSM in Mexico who "live lives in denial" frequently engage in high-risk sex but do not acknowledge it to anyone. MSM also are often hard to reach in HIV prevention and education campaigns because they tend to ignore prevention messages if they believe they are targeted toward gay men (Lacey, New York Times, 8/7). A video on the Times Web site on Wednesday highlighted how sexual ambiguity, including denial and discrimination, in Mexico forces some people to be secretive about their behaviors, which hinders efforts to fight HIV/AIDS (New York Times video, 8/6).
Multimedia Coverage
NPR's "All Things Considered" on Wednesday included a discussion about the AmfAR report. The segment includes comments from an HIV-positive MSM living in North Carolina (Wilson, "All Things Considered," NPR, 8/6). Audio of the segment is available online.
Researchers examine use of antiretrovirals as HIV prevention method
Some researchers on Wednesday at the XVII International AIDS Conference in Mexico City examined how expanding national HIV/AIDS treatment programs could prevent the spread of HIV, the Wall Street Journal's "Health Blog" reports. According to researchers, countries should vastly expand their antiretroviral treatment programs to include all people in need of the drugs not only out of human-rights concerns but because using drugs to lower HIV viral loads on a population-wide scale could reduce transmissions of the virus, "Health Blog" reports.
Although the use of antiretrovirals to prevent HIV is being examined in trials with pre-exposure prophylaxis, Julio Montaner of the British Columbia Centre for Excellence in HIV/AIDS -- who also is the incoming chair of the International AIDS Society -- said that the drugs can be used as a secondary prevention method. By ensuring universal access to antiretrovirals, thereby reducing HIV-positive people's viral loads and the risk of HIV transmission, countries might be able to help prevent further spread of the virus, according to Montaner. He added that preliminary studies in Taiwan and Vancouver offer hope for this method. Kevin De Cock of the World Health Organization said that he is waiting for data to validate the method. "There's biological plausibility, but not proven efficacy," he said (Chase, "Health Blog," Wall Street Journal, 8/6).
Research examines role of truck drivers in HIV/AIDS along routes in Africa
Research presented this week at the XVII International AIDS Conference in Mexico City examined the role of truck drivers in the spread of HIV/AIDS in Africa, IRIN/Plus News reports.
Alan Ferguson, a researcher at Constella Futures, and colleagues conducted a study that examined HIV vulnerability along the transport corridor linking Kenya's port city of Mombasa to Kampala, Uganda. Along this route, the researchers found that truckers accounted for 30% of the clients of female commercial sex workers. In a similar study, conducted along the route from Kampala to Juba, Sudan, researchers found that truck drivers accounted for 28% of clients of commercial sex workers and that other clients came from a broad range of occupations.
According to the Constella Futures study, about 2,400 trucks park overnight between Mombasa and the Ugandan border at 39 highway stops, which attract approximately 5,600 commercial sex workers. In addition, studies have found that many road transportation workers engage in unprotected sex, IRIN/Plus News reports.
According to Ferguson, HIV/AIDS awareness programs need to "go beyond" truckers and involve communities surrounding highway stops. The HIV/AIDS Corridor Project -- a regional initiative supported by UNAIDS, the World Bank and USAID -- targets people using the highway between Abidjan, Cote D'Ivoire, and Lagos, Nigeria. Justin Koffi, executive director of the project, said that West African communities surrounding border posts are just as vulnerable to HIV as truck drivers and commercial sex workers. Koffi added that studies have found that HIV prevalence in border communities is two times higher than national averages, but awareness programs remain weak in these regions. Asif Altaf, HIV/AIDS project coordinator for the International Transport Workers' Federation, added that prevention programs need to address the families of truck drivers, "otherwise the cycle will continue."
United Nations Special Envoy for HIV/AIDS in Africa Elizabeth Mataka warns against blaming truck drivers for the spread of HIV, noting that poor working conditions make drivers vulnerable. Altaf added that truck drivers receive low wages and work alone for long periods of time away from home. In addition, drivers often experience long delays while waiting for customs to clear goods at national borders. According to Altaf, in such instances sex can be a means of coping (IRIN/Plus News, 8/4).
Male Mexican migrant workers have increased risk for HIV after arrival in U.S. because of changes in sex habits, study finds
Mexican migrant workers significantly change their sex habits and increase their risk for HIV after they arrive in the U.S., according to a study conducted by the Pilot Program of California-Mexico Epidemiology Vigilance and released on Tuesday at the XVII International AIDS Conference in Mexico City, AFP/Google.com reports. The study involved 458 male Mexican migrant workers ages 18 to 69 who arrived in the U.S. during the past five years. Researchers conducted the study in California, where about 40% of Mexican immigrants live, in conjunction with state and Mexican authorities and social groups.
According to the study, the percentage of male Mexican migrant workers who had sexual relations with commercial sex workers increased from 18.1% to 29.4% after they arrived in the U.S. The study also found that the percentage of male Mexican migrant workers who had sexual relations under the influence of alcohol increased from 24.6% to 41.3% after they arrived in the U.S. However, the study found that 81.4% of male Mexican migrant workers regularly used condoms before they arrived in the U.S., compared with 65.1% after they arrived.
Melissa Sanchez, who presented the study, said that male Mexican migrant workers ages 18 to 29 are at the highest risk for HIV as a result of their sexual practices (AFP/Google.com, 8/5).
People living with HIV/AIDS in Canada have difficulty obtaining organ transplants, advocates say at AIDS conference
People living with HIV/AIDS in Canada often have difficulty obtaining organ transplants in the country, Canadian HIV/AIDS advocates said at the XVII International AIDS Conference in Mexico City, Toronto's Globe and Mail reports.
Although there is no rule preventing HIV-positive people from receiving organ transplants, it is "next to impossible to get it done in Canada," Curtis Cooper, a physician at the Viral Hepatitis Clinic at Ottawa Hospital, said. HIV-positive people in several countries -- including France, Spain, the United Kingdom and the U.S. -- have been receiving organ transplants for about 10 years, the Globe and Mail reports.
Cooper said that many surgeons incorrectly believe that HIV-positive people are poor candidates for organ transplantation because transplant recipients are required to take immune-suppressing drugs. However, studies have shown that immune-suppressing drugs do not cause HIV to progress, according to the Globe and Mail. Cooper added that the majority of liver transplants in Canada are performed on people living with hepatitis B or hepatitis C. Many of those with hepatitis B or C also are HIV-positive. "I'm not asking for special access for those who are coinfected [with HIV and hepatitis], just fairness in access," Cooper said.
Louise Binder, chair of the Canadian Treatment Action Council, said physicians are discriminating against HIV-positive people based on "specious arguments," such as a shortage of organs or concerns that surgeons will contract HIV during surgery. "It's true that organs for transplant are in short supply, but, nonetheless, those with HIV, [hepatitis] B or C can be equally good candidates," Binder said.
She added that concerns that HIV could be transmitted during surgery are invalid because surgeons take precautions with all patients and HIV-positive people undergoing surgery likely would be nearly noninfectious because of antiretroviral drugs. In addition, surgeons regularly operate on people with hepatitis, which is more infectious than HIV, Binder said.
According to the Globe and Mail, about 58,000 people are living with HIV/AIDS in Canada, about one-third of whom also have hepatitis. Cooper estimated that about 50 of those people coinfected with HIV and hepatitis would require liver transplants, and even fewer would require kidney transplants (Picard, Globe and Mail, 8/6).
Tool kit for HIV-positive children released at international AIDS conference
The Southern Africa HIV and AIDS Information Dissemination Service launched a tool kit on children and antiretroviral therapy on Sunday at the XVII International AIDS Conference, Zimbabwe's Herald/AllAfrica.com reports. According to SAfAIDS, the tool kit is a "vibrant" package of informative and interactive material to be used by children and their teachers, health care workers, parents and guardians.
The tool kit includes a booklet on children and antiretrovirals, a children's adherence calendar and a watch, as well as an HIV and antiretroviral game and quiz cards to expand children's knowledge of HIV/AIDS (Herald/AllAfrica.com, 8/5).
AIDS 2008 Daily Roundup
Participants at the XVII International AIDS Conference in Mexico City on Wednesday heard about the future of the epidemic from a variety of perspectives. According to Anthony Fauci, M.D., Director of the National Institute of Allergy and Infectious Diseases, research possibilities are "bright and promising." "However, here we are in Mexico City still in the middle of a raging pandemic," said Fauci. "To be sure there are multiple and daunting challenges ahead in terms of how we confront HIV globally. Not all but certainly some of these challenges can only be addressed through biomedical research."
Those biomedical advancements, which for the time being remain elusive, include a vaccine and a cure for HIV.
Robert Siliciano, M.D., Ph.D. Professor of Molecular Biology and Genetics, Johns Hopkins University School of Medicine, outlined the three steps necessary for eradicating HIV from an infected person's body. The first is stopping HIV from replicating, which he says has already been accomplished with current treatment methods. The second is identifying the areas of the body where HIV still persists. And third is eliminating HIV from those reservoirs.
"Treatment failure is not inevitable," Siliciano said. "Even with the drugs we have today or with forms of the drugs that are very similar to what we have today, if we could develop forms of these drugs that could be taken for life with acceptable levels of toxicity than its, in principle possible, to offer everyone who is currently living with HIV infection the chance for a normal life. This is the long term challenge that all of us face."
Current treatment methods are extending the lives of three million people worldwide, though millions more are not getting access to the drugs they need. Despite a doubling of children on antiretroviral therapy over a two year period, the vast majority of the more than two million children living with HIV are not getting therapy. "Prevention, care and treatment for children continue to lag behind adults," said Linda Richter, Ph.D. with the Human Sciences Research Council. "Support for affected children has been left largely to families, extended kin and communities. Although they are the most appropriate group to care for children, they cannot protect and care for children without assistance."
Criminalization of sex work was also discussed today as a driver of the epidemic.
Elena Reynaga RedTraSex argued for decriminalization and reducing the stigma associated with sex work.
"When there is a country that discriminates, that is conservative, that criminalizes sex work, the prevalence of HIV is higher," she said.
Community advocates at the conference expressed the need to raise up new leaders in the fight against HIV.
"How can we think beyond what we see today?" asked Vuyiseka Dubula with the Treatment Action Campaign. "If the policy is bad today what will it mean for the next 20 years, 50 years? So that we start building campaigns building towards 2031, because by 2031 if we haven't done anything it might be too late."
AIDS 2008 New Studies and Development
Kaiser Daily HIV/AIDS Report summarizes reports, initiatives from international AIDS conference
As part of its expanded coverage of the XVII International AIDS Conference, which is being held Aug. 3 through Aug. 8 in Mexico City, the Kaiser Daily HIV/AIDS Report will feature studies and initiatives released during the conference. Summaries of select publications and initiatives appear below.
"2008 Pipeline Report (.pdf)," Treatment Action Group: The annual report reviews medical technologies that could be beneficial to HIV-positive people within the next few years, including antiretroviral, tuberculosis, hepatitis B and C drugs; diagnostics; vaccines; and microbicides. According to the report, the past five years of inert public research funding, which has resulted in a 20% decrease in real dollars adjusted for inflation, have begun to affect development of new interventions to prevent and treat HIV/AIDS, TB and hepatitis B and C. The report calls for increased public funding for biomedical research, with a five-year, 15% annual increase in funding recommended for NIH. The report also says that greater investment in HIV, TB, and hepatitis research is needed by wealthy and developing countries worldwide (TAG release, 8/3).
"From the Ground Up: Building Comprehensive HIV/AIDS Care Programs in Resource-Limited Settings," Elizabeth Glaser Pediatric AIDS Foundation: The foundation produced the publication with support from the "A Day in the Life of Africa" Foundation/Tides Foundation, the U.S. government, Harvard University and other groups. The guide aims to improve and expand HIV/AIDS prevention, care and treatment efforts in resource-limited settings. The three-volume publication contains guidelines designed and written for health care providers, managers, policymakers and implementers, as well as the academic community (Elizabeth Glaser Pediatric AIDS Foundation release, 8/5).
"The Life Initiative: Hotels Addressing AIDS," UNAIDS/IMPULSO/CONAES: The initiative is aimed at hotel guests and staff in Mexico and hopes to raise awareness about HIV prevention and discrimination. It also will promote the creation of sustainable HIV/AIDS workplace policies and programs in hotels. The prevention campaign will include the display of HIV/AIDS-related leaflets, posters and brochures; art exhibitions; distribution of no-cost male and female condoms; and HIV/AIDS-related films in all participating hotels (UNAIDS release, 7/23).
"Make it Matter (.pdf)," United Nations Population Fund: The report focuses on three goals that it says should be central components of a successful response to HIV/AIDS -- improved access to sexual and reproductive health for girls and young women; the expansion of socioeconomic opportunities for girls and young women; and the end of child marriage. The report also presents national experiences on HIV/AIDS prevention with the aim of scaling up successful initiatives (UNFPA release, 8/6).
In The Courts
Court finds Kyrgyz physicians guilty of HIV transmission
A court in Kyrgyzstan recently sentenced nine physicians to prison for negligence that resulted in HIV transmission to children in several hospitals across the south of the country, according to a judicial source, AFP/Yahoo! News reports. According to AFP/Yahoo! News, the physicians were given prison terms ranging from three to five years and ordered to pay $10,000 in damages and interest to the children and their families.
Prosecutors said 41 children and four mothers contracted HIV at two hospitals in Kyrgyzstan (AFP/Yahoo! News, 8/6). Charges of negligence were filed against 14 medical workers who were believed to have accidentally infected the children through tainted blood and used needles. Four Kyrgyz physicians were also fired in July 2007 for accidentally infecting 10 children and one adult with HIV. Ministry of Health officials said the children and the adult contracted HIV while receiving injections and blood transfusions. Hundreds of children have been tested since the outbreak was first discovered in July 2007 (Kaiser Daily HIV/AIDS Report, 4/11).
The health ministry declined to comment on Tuesday.
According to Reuters, HIV/AIDS levels have "skyrocketed" across Central Asia since the collapse of the Soviet Union in 1991, mainly among drug users and prisoners (Reuters, 8/5).
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