by Emma Hitt, PhD

Nurse-managed care of patients receiving antiretroviral therapy (ART) for HIV may result in comparable outcomes to physician-managed care and enable expanded access to care in resource-poor settings.

Ian Sanne, MD, from the University of the Witwatersrand, in Johannesburg, South Africa, and colleagues with the Comprehensive International Program for Research in AIDS in South Africa conducted a randomized noninferiority trial at 2 South African primary-care clinics. They published their findings online June 16 in The Lancet.

According to Dr. Sanne and colleagues, a shortage of 4.3 million health workers (ie, physicians, midwives, nurses, and support workers) exists worldwide, and only 17.4 medical practitioners, most located in urban areas, are available to treat 100,000 people in South Africa.

To compare outcomes of nurse vs physician management of physician-initiated ART care for HIV-infected patients, researchers randomly assigned HIV-positive individuals with a CD4 cell count of fewer than 350 cells per microliter or World Health Organization (WHO) stage 3 or 4 disease to ART care monitored by either nurses (n = 404) or physicians (n = 408).

Treatment failure was defined as a composite of the following endpoints: traditional virological failure, occurrence of dose-limiting toxic effects, death, and all clinic losses that translated to failure of the treatment strategy to maintain patients on ART.

Of the patients, 46% demonstrated treatment failure — 48% in the nurse group and 44% in the physician group (hazard ratio, 1.09; 95% confidence interval, 0.89 – 1.33), which was within the limits for noninferiority.

Other outcomes at a median follow-up of 120 weeks were also comparable between the nurse- and physician-monitored patients, including deaths (10 vs 11), virological failures (44 vs 39), toxicity failures (68 vs 66), and program losses (70 vs 63).

According to the researchers, approximately 16% to 17% of patients were considered treatment failures because of the dose-limiting toxic effects of stavudine, which included a high frequency of lipomorphological changes and lactate increases.

“WHO and South African guidelines have moved away from reliance on stavudine; however, this drug remains widely used in resource-poor HIV therapy programmes,” they write. “The dose reduction of stavudine to 30 mg after the first year of the study, which was in line with WHO recommendations, might have reduced drug-limiting toxic effects,” they add.

“The results of this study lend support to the expanded access to treatment with use of models of task shifting in primary health care,” the authors conclude.

Independent commentators Mark Boyd, MD, from National Centre in HIV Epidemiology and Clinical Research and St Vincent’s Hospital, , Sydney, Australia, and Chidi Nwizu, MBBS, from the University of Maryland School of Medicine, in Baltimore, point out that “it is marvellous to see the results of a practical and innovative study which helps propel the field forward and improves our collective confidence that despite all the obstacles we can succeed.”

However, they add that many HIV-infected patients reside and access care in rural areas. “The study sites in [the Comprehensive International Program for Research in AIDS in South Africa] were not rural and had reasonable access to laboratories and ancillary services,” they write. “These are potential challenges in decentralisation models that include task-shifting.”

The study was supported by the National Institutes of Health, the US Agency for International Development, and the National Institute of Allergy and Infectious Diseases. The authors and Dr. Nwizu have disclosed no relevant financial relationships. Dr. Boyd serves on an HIV advisory board for MSD Australia and for Bristol-Myers Squibb Australia; has received funding and/or has partnered with Merck, Abbott, and the American Foundation for AIDS Research; and has spoken at events for Abbott and Merck, received honoraria from MSD Australia and Janssen-Cilaq Australia, and serves as vice president of the Australasian Society for HIV Medicine.

We, the UNITAID board members representing non-governmental organisations (NGOs) and communities affected by HIV/AIDS, tuberculosis, and malaria, are writing to you to express our deep concern that Bristol-Myers Squibb (BMS) is to close a factory in France that manufactures a second-line antiretroviral medicine for children with HIV/AIDS who weigh less than 10 kg: buffered didanosine in the 25 mg formulation.
Closing this factory means that 4000—7000 babies currently enrolled in treatment plans in developing countries through UNITAID could be left without the medicines they need. Didanosine is the last therapeutic option for these babies and without it they could die. We understand that closure of the plant will take place in June of this year, with no plans for resumption of production before April, 2011, at the earliest, when a new plant is due to open. Therefore there is likely to be a shortage of about 15 000 packs of didanosine 25 mg across all UNITAID beneficiary countries between now and when production is expected to resume in April, 2011.
Currently, there is no alternative generic product that has been assessed by WHO and prequalified for use by UN agencies. We urge you, as the Chief Executive Officer of BMS, a company that prides itself on its high standards of corporate responsibility, to respond urgently to our concerns, outlining the steps you will take to avoid any treatment interruption. We would also like your confirmation that a BMS plant will resume production of this vital medicine in 2011.

Many developed countries – including the UK – have a lifetime ban on blood donations from men who have ever had sex with other men, even if the encounter took place many years earlier.

The policy was introduced in the early 1980s as the threat of HIV/Aids emerged.

But writing in the Canadian Medical Association Journal, Mark Wainberg and Norbert Gilmore note that the highly sensitive procedures now routinely used for testing mean it would be very hard for infected blood to slip through.

It was time, they said, to consider scrapping the old policy of “indefinite deferral” and look at asking men to wait between one and five years after having sex with another man before giving blood.

“The current policy is counterproductive in terms of loss of donors, loss of good will, student protests, donor boycotts, among other negative effects,” they write.

“We believe that any potentially negative consequences of a change in deferral would be offset by the benefits.”

Transmission time

Opponents of the lifetime ban point to new testing techniques which are able to detect the HIV virus in the blood after as little as 12 days – down from three to six months previously.

Thus a “window” where infected blood might unknowingly enter the supply system remains, but it is a very short one. And opponents of the lifetime ban also point to the moral issue of double standards.

http://news.bbc.co.uk/1/hi/health/10163222.stm

Interestingly a paper from BMJ (http://www.bmj.com/cgi/content/full/338/feb26_1/b318) holds a very different opinion.

It’s quite a prompt way to share front-line informaiton or so. I like the idea but haven’t found their daily updates are really useful yet.

A clinical trial of a vaccine against a major cause of pneumonia and meningitis has shown that it can prevent three out of four cases of reinfection in HIV-infected adults in Africa.

http://www.aidsmap.com/en/news/BEF8C8CE-BC45-4DD4-B859-00E42D5F9459.asp

TB Trials

Circumcision is thought to protect men from HIV infection because foreskin tissue appears particularly susceptible to the virus, and may serve as an entry point for it. However, circumcision would not affect HIV risk from receptive anal sex — and that, again, could outweigh any protective effect of circumcision during insertive sex.

A review in journal of Urol on three randomized, controlled trials concluded that “circumcising adult males reduces the incidence of HIV by 50% to 60%. Adult male circumcision does not seem to have an adverse impact on sexual function. Epidemiological and economic modeling suggests that adult male circumcision can potentially be a highly cost-effective strategy for HIV prevention. ” (The impact of male circumcision on HIV transmission, Doyle,S.M.; Kahn,J.G.; Hosang,N.; Carroll,P.R.)

A report from CDC consultation published in this year Public Health Rep.
suggested that (1) sufficient evidence exists to propose that heterosexually active males be informed about the significant but partial efficacy of MC in reducing risk for HIV acquisition and be provided with affordable access to voluntary, high-quality surgical and risk-reduction counseling services; (2) information about the potential health benefits and risks of MC should be presented to parents considering infant circumcision, and financial barriers to accessing MC should be removed; and (3) insufficient data exist about the impact (if any) of MC on HIV acquisition by MSM, and additional research is warranted.

A little bit history here from AIDSInfo: Lopinavir/ritonavir in capsule and oral solution form was approved by the FDA on September 15, 2000, for use with other antiretrovirals in the treatment of HIV infection in adults and children 6 months of age or older. Lopinavir/ritonavir in tablet form was approved by the FDA on October 28, 2005. In March 2006, the capsule form of the medicine was phased out in the U.S. in favor of the new tablet.

once-daily dosing of lopinavir/ritonavir tablets and oral solution means lopinavir/ritonavir can be used noce or twice a day (as recommended before) combining with other therapies. This will be an easiler way of treatment and may reduce further poor adherence among HIV-diagnosed patients, which is critical for immunosupression and virological suppression.

1. The few HIV prevention campaigns that do exist do not target the elderly.
2. Older people may not consider themselves at risk of HIV infection.
3. Health care providers may not consider the diagnosis in older patients and therefore may not undertake HIV testing or may attribute symptoms of HIV to ‘normal ageing’.
4. Despite the stereotypes, many older people lead sexually active lives. Studies of sexual activity in people aged over 50 showed that 81.5% were involved in one or more sexual relationships including sex with prostitutes,and a national US survey suggested that only a small minority of people over 70 consistently used condoms. Older women may be especially at risk because age-related vaginal thinning and dryness can cause tears in the vaginal wall.
5. The increase in foreign travel makes access to countries with thriving sex industries easier.
6. The introduction and usage of potency drugs has extended the sex lives of many elderly males.
7. Injection drug usage, despite our misconceptions, is a contributor to HIV transmission in older people. In the USA, injection drug use accounts for more than 16% of AIDS cases in those aged 50 or over.
8. The stigma of HIV may be perceived to be greater in the elderly population leading them to hide their diagnosis or avoid testing.

The paper is a very good review in Age and Aging. My colleague – Ruth Smith present some important findings at the joint conference of the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASHH) last week. In the United Kingdom, one in twelve HIV diagnoses are of a person over the age of 50. Whilst rates of late diagnosis are high in older adults, just under half of these diagnoses are thought to be of an infection that was acquired when the person was over the age of 50.

It’s a good thing though. We need to bring people together to remove stigma related to HIV. China authority said this change won’t have a significant impact on the HIV epidemic in China. Yes and No. In China, the most serious problem is internal migration. It benefits the economic development a lot but inevitably causes problems such as prostitution, education, transportation, pollution etc etc. Most international population movement is actually emigration instead of immigration. Because of the small proportion of HIV positive individuals of the whole immigration population, it probably won’t make a big difference. However, in an other hand, several factors may effect the epidemic, for example, short-term visitors are likely to engage in risky behaviour, condom use is still not very common in China despite of free provision, many young girls favour foreigners for various reasons, HIV testing requests a lot a lot more efforts to promote, Chinese hold very different attitudes toward testing, treatment, sex and HIV compared to Britain and Americans. ….

If let the whole nation vote, the proposal might wouldn’t get passed. Thanks we are not a democracy country! pros and cons.

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the following informaiton is from http://news.yahoo.com/s/ap/20100428/ap_on_re_as/as_china_aids

China lifts travel ban against people with HIV/中国不再禁止国外艾滋病等患者入境.

BEIJING – China has scrapped a 20-year travel ban that barred people with HIV and AIDS from entering the country, just days ahead of the opening of the Shanghai Expo, which hopes to welcome millions of overseas visitors.

The decision announced by China’s Cabinet, the State Council, follows similar moves by the United States and South Korea to eliminate travel restrictions for people with the HIV virus. Both lifted their bans on visitors with HIV on Jan. 1.

China’s ban had been launched based on “limited knowledge” of HIV at the time and had proven inconvenient for the country when hosting international events, the official Xinhua News Agency quoted the Cabinet as saying. The Shanghai Expo begins Saturday and runs for six months.

The State Council said in a statement posted to its website late Tuesday that the government passed amendments on April 19, revising the Border Quarantine Law as well as China’s Law on Control of the Entry and Exit of Aliens. The changes were effective immediately.

The move also includes scrapping entry restrictions for people with leprosy and sexually transmitted diseases.

The State Council said that the government realized such restrictions had limited effect on preventing and controlling the spread of diseases in the country, according to Xinhua. The Cabinet did not immediately respond to faxed questions.

AIDS was the top killer among infectious diseases in China for the first time in 2008, a fact that may reflect improved reporting of HIV/AIDS statistics in recent years. Despite greater openness, the government remains sensitive about the disease, regularly cracking down on activists and patients who seek more support and rights.

Government statistics show that by the end of October 2009, the number of Chinese confirmed to be living with HIV-AIDS was 319,877, up from 264,302 in 2008 and 135,630 in 2005. But Health Minister Chen Zhu has said the actual level of infections is probably near 740,000.

U.N. Secretary-General Ban Ki-moon welcomed China’s decision and urged other countries that still bar people with HIV to change their laws as soon as possible. “Punitive policies and practices only hamper the global AIDS response,” he said in a statement.

News from the 17th. conference on retroviruses and opportunistic infections
San Francisco has promoted HIV testing so well that only one in seven people with HIV are undiagnosed.

In South Africa, nearly a quarter of patients eligible for HIV therapy died while on the waiting list.
(ref: Montaner j et al. Association of expended HAART coverage with a decrease in new |HIV diagoses, particularly among injection drug users)

Researchers from the DAART trial in Uganda and Zimbabwe found that within a year of starting treatment, 78% of patients had not achieved a CD4 count over 350 cell/mm3 and nearly half had not reached 200.
(ref: Munderi P et al. Immune restoration over 5 years on ART among patients initiating treatment with advanced immune deficiency in the DART trial in Uganda and Zimbabwe)

HIV transmission in long-term hetrosexual relationships could not be prevented by treating herpes. The rate of transimission from a HIV-positive patner was reduced from 2.25% to 0.39% a year when they started treatment.

Partners with CD4 counts under 200 cells/mm3 were five times more likely to transmit HIV than others.