Tuesday, December 29, 2009

Holidays half over; treatment plans intact?

Many people are aware that current treatment plans involve a lifetime committment. This means whether once-per-day or twice, whatever combination of medicines is prescribed needs to be taken in the same way at the same time, daily, as instructed.

This can be very challenging during holiday periods: There may be travel involved (which may include time-zone changes); there could be guests visiting or being visited (which might mean a change in how, where and to what degree the prescription-taking is visible to others, and to whom); there may be changes in eating and also drinking patterns (possibly involving parties, dinners, get-togethers and other things) and this combination needs to be accounted for in our holiday planning.

While a great majority of the "rush" of the season is now behind us all, there are still a few more days (almost a week, in fact) when many people are still away, or otherwise not yet returning to normal routines, be they work, school or whatever.

How are you coping? Has it been a challenge? Was there some adjustment? Did it all go well? Were there some rough patches?

Nobody is perfect, for if we were, how "human" would we be? Still, where possible, we must try to give the research and team of healthcare professionals who are literally working on our behalf the best possible outcome they've worked for - and this is not to mention our own selves... for we deserve it - by trying to account for these holiday-period changes and recognizing the challenges, where possible, ahead of time. Planning for that, and doing what we need to do to accommodate these differences in our daily routines, will go a tremendously long way toward the success of our treatment plan and toward better health outcomes for us!

Here is hoping that 2010 is the year when it all comes together, if it hasn't; and here's also hoping that the gains of 2009 improve while the pains lessen in this coming year. To whatever extent we have control over these issues, here's hoping we'll take that control and use it wisely, and that to whatever extent it's out of our hands, we are favoured with nothing but the best!

Monday, December 21, 2009

The Season

At a time in the year when people's thoughts turn to holidays of one kind or another, whether travelling or hosting, whether near or far; regardless of religion or not, and with the emphasis on getting it all done, no matter what that may be (even just stocking up on supplies when things are closed down for so long): How do people cope? How does anyone cope with the rush, the demands, and the resulting stress that is seasonally ours - subscriber or not?

For some, it may be just turning to those they regularly seek out and are with; others may find comfort in finding long-ago (even recent) folks who've moved, been less involved or are otherwise distant. Reducing stress is shown to be of benefit in healthcare settings of all kinds, whether just helping to reduce blood pressure or helping with behaviour changes that reduce risk and include harm reduction measures. Friends, family and even strangers may have it in them to help, but we have to let them or seek it, or at least actively engage. Whatever way one does it, make sure that this holiday season, there is something in your stockings (whether hung or worn) that really helps take stress levels down as much as one can. You'll feel and be better for it!

So, what reduces your stress?

Friday, December 18, 2009

Most important considerations in choosing a regimen?

Anti-retroviral medications have improved, over time, with fewer (and sometimes better-managed) side effects, reduced numbers of required pills and less-frequent dosing.

Choosing the right medication combination is a very personal thing, and even each HIV specialist differs in their approaches: Some will choose a regimen that is very defensible while others prefer different choices. The choice often rests on the individual patient's priorities: Does the number of pills really seem important? For some, even many, it will. Is there any difficulty with varying day-to-day schedules (work, sleep, travel, etc...) making dosing schedules an important consideration. Are there certain other medications already (or likely to be) used to control such things as diabetes, high blood pressure, cholesterol issues (particularly triglycerides)? Interactions with certain medications is an issue. Is there a co-infection with hepatitis B or hepatitis C? This can influence the choice of medication and even the decision to start treatment or not. Is it likely that food will always be available at the specific time when one needs it for the medication (if the medication requires food)? For those who travel and who don't generally eat breakfast, this may influence once-a-day dosing scheduling as well as help decide whether or not once- or twice-a-day is best. And that can also lead to influencing decisions regarding which medication to choose as, for example, efavirenz (Sustiva) is often taken at nighttime in order to help manage certain possible side effects; however, there may be reasons to avoid that medication, so a different one may be needed.

For those folks being recommended to start treatment, these are among the questions that need to be thought out. If they are considered ahead of your appointment with the HIV specialist, a fuller discussion can be had and the result will be a better-tailored medication regimen that will work and that you can adhere to, which is the greatest single factor within our control that can prevent resistance developing by the virus to the medications... and obviously, that will lead to better health outcomes.

Tuesday, December 8, 2009

Starting Treatment & Patient-centred care

The question about when to start treatment has been a hotly-debated one, and over time, the target has been moving back-and-forth between lower and higher numbers of CD4s as a base for recommending the beginning of antiretroviral use. However, the decision remains a personal one that each individual must make in connection, and after discussion, with his or her healthcare provider. Gone are the days where one simply presents to a doctor with an illness and whatever is handed for treatment is taken without question. Patient-centred care is not only a valid buzzword but also a most necessary part of decision-making: When medications no longer have side effects, when food no longer needs to be taken, when housing and other necessities of life are fully assured, then there might be every reason to follow the doctor's advice without question, but still: You have a choice. Things must be carefully weighed and balanced, both medical considerations as well as personal ones, and the decision remains an individual one. If you need help making such a lifelong committment to treatment, you're not alone; there is support, and there are professonals to speak with who may be able to help with the reasoning process, and other important actions, as well. The take-home message is that one doesn't simply take a strong medical recommendation and follow it blindly without thinking about what it means. It has to be a balanced and thoughtful approach toward treatment. What do folks think about this?

Tuesday, December 1, 2009

World AIDS Day

Today is World AIDS Day. You may be hearing about funding cuts to HIV community based organizations in the Vancouver area today. How does this affect your health? Programs and services are needed for HIV-positive individuals as each year sees approximately 200-300 new HIV-positive results. What do you think of this? Share your thoughts on this.

Monday, November 23, 2009

HIV and Belly Fat

Belly fat is an issue for HIV-positive individuals (also known as lipodystrophy) and is a side effect of some HIV medications. As individuals age, they may also develop body fat especially with poor diet. Diet and exercise are increasingly important to reduce body fat. Some individuals have used alternative treatments to reduce fat levels. Tesamorelin is a new drug used for belly fat that has shown promising results so far. What have you been doing? Are you concerned about belly fat and what do you wish to know?

Thursday, November 12, 2009

Naturopathy and HIV

BCPWA Treatment Information Program has started up an HIV Complementary Care Clinic which runs every Wednesday evening. This is a partnership with the Boucher Institute of Naturopathic Medicine in which naturopath students provide treatments under the supervision of a naturopath. Some of the naturopathic treatments available include: acupuncture, vitamin & mineral supplementation, nutritional counseling, homeopathy and botanical medicine. Have you used such treatments and what has been your experience? Share with us.

Tuesday, November 3, 2009

Cancer and HIV - News

There was a recent journal article from Lancet reporting that both non AIDS related and AIDS related cancer can occur earlier for HIV-positive individuals with low CD4 counts - by as much as 20 years earlier! This is another argument for starting treatment earlier to get your CD4 counts high and viral load to undetectable. What do you think of this?

Tuesday, October 27, 2009

H1N1

We've been away for a while and now back. The big news of this fall season is H1N1 (or also called swine flu). Flu risk is highest from November to March and this year, we expect both regular flu and H1N1. People with chronic conditions, like HIV, are at greater risk & the H1N1 vaccine is now available. Ask your doctor if you should be vaccinated. Do you have any questions for us? What do you wish to know about H1N1 & we'll try our best to answer. Also, if you have experienced H1N1, let us know on here how you managed.

Thursday, July 23, 2009

2009 INT'L AIDS SOCIETY CONFERENCE - SOUTH AFRICA - FINAL DAY

Here is the final summary of some main events occurring in Capetown, South Africa, at the International AIDS Society’s 2009 5th Conference on HIV Pathogenesis, Treatment and Prevention. The Conference concludes on Wednesday, July 22nd.

Again, please remember that it is always difficult, and is a necessarily subjective process, to cull from various sources and limit the detail while offering such coverage.

Once more, the official sources for this information (as suggested by the Conference organizers) are:

- The Live Conference Blog
- News Releases
- Facebook
- twitter
- Clinical Care Options
- Rapporteur summaries

For more in-depth information on these and other subjects arising from this Conference, please visit: http://www.ias2009.org/


I HOPE THE MATERIAL, THIS WEEK, HAS BEEN OF INTEREST.





CANADA’S OWN STEPHEN LEWIS
(earlier this week)








Darunavir/ritonavir monotherapy does well

Two separate studies have shown that treatment with ritonavir-boosted darunavir (Prezista) monotherapy may be a viable option after a person has first suppressed their viral load to undetectable levels using conventional triple-drug HIV therapy.

The first of the studies (MONET) involved 256 patients in Europe. All had suppressed their viral load to below 50 copies/ml for at least six months using a combination of three drugs that included darunavir/ritonavir.

Half the patients were randomised to continue taking triple therapy, whereas treatment for the others consisted of darunavir/ritonavir only.

After a year equal proportions of patients (approximately 85%) maintained an undetectable viral load.

The second study (MONOI) was conducted in France and involved 225 patients. This also demonstrated the non-inferiority of darunavir/ritonavir monotherapy to standard three-drug treatment.



[I think this was reported on Wednesday – but this shows more detail, today.]

Boosted and unboosted atazanavir both effective

A two-year study has shown that atazanavir (Reyataz), regardless of whether it is boosted by ritonavir, is effective at suppressing viral load to undetectable levels when used as part of triple-drug antiretroviral therapy.

After 84 weeks of follow-up, 86% of those taking unboosted atazanavir had a viral load below 50 copies/ml, compared to 81% of those treated with the boosted version of the drug.

Gains in CD4 cell counts were comparable, but the research showed that individuals taking unboosted atazanavir were less likely to develop the side-effect hyperbilirubinaemia than those taking atazanavir/ritonavir (4% vs 10%). Furthermore, cholesterol fell in those taking the unboosted drug, but it increased in those treated with the ritonavir booster.


Aciclovir reduces risk of HIV disease progression and death
Twice-daily treatment with the anti-herpes drug aciclovir significantly reduced rates of HIV disease progression and death, a study has shown.
The study involved 3408 HIV-positive patients. They were randomised to take either twice-daily doses of aciclovir (400mg) or a placebo.
Patients taking the anti-herpes drug were 19% less likely to need to start HIV treatment, a finding that was of borderline significance. Moreover, they were significantly less likely to experience a fall in their CD4 cell count to below 200 cells/mm3.
Although treatment with the drug reduced the risk of HIV transmission to a negative partner by 17%, this finding was not significant.


Successful treatment for hepatitis C improves liver damage in co-infected patients

Individuals co-infected with HIV and hepatitis C who have a successful response to hepatitis C treatment with pegylated interferon and ribavirin experience an improvement in their liver fibrosis and, in some cases, cirrhosis, according to new research.

The study involved 294 patients. All had a liver biopsy and were assessed after 44 months after completion of hepatitis C therapy using FibroScan.

An improvement in fibrosis was observed in 36% of individuals who had a sustained response to this treatment. There were even cases of cirrhosis improving.

Statistical analysis showed that successful hepatitis C treatment was the only factor significantly associated with an improvement in fibrosis.


Anal cancer

US research has shown that new diagnoses of anal cancer in HIV-positive men are increasing.

The rate of anal cancer increased from 11 per 100,000 before HIV treatment became available in 1996, to 55 per 100,000 between 1996 and 2008.

An AIDS diagnosis and a low nadir CD4 cell count were significantly associated with the risk of developing the malignancy.

A second study showed that 53% of HIV-positive men with anal human papilloma virus were not infected with the strains of the virus most associated with a high risk of anal cancer.

This finding suggests than many HIV-positive individuals could benefit from receiving the new vaccines that offer a very high level of protection against the strain of human papilloma virus most associated with genital cancers.


Three ART Combinations Lower MTCT Rate During Breastfeeding to 1%
Author: Mark Mascolini

--------------------------------------------------------------------------------

22 July 2009

Three antiretroviral therapy (ART) combinations taken before and after delivery by women in Botswana all controlled viral replication in the women and kept mother-to-child transmission rates at 1% throughout breastfeeding—the lowest rate yet recorded during breastfeeding by HIV-infected women.

The study involved 730 HIV-positive women, 560 of them with a CD4 count above 199 cells/µL randomized to coformulated abacavir plus zidovudine plus lamivudine or to lopinavir/ritonavir plus coformulated zidovudine/lamivudine. The 170 women with a CD4 count below 200 cells/µL took nevirapine plus coformulated zidovudine/lamivudine.

HIV RNA suppression in women did not differ significantly between the two randomized arms at delivery (96% with abacavir versus 93% with lopinavir, P = 0.18) or throughout breastfeeding (92% versus 93%, P = 0.98). The nonrandomized nevirapine group also had high viral suppression rates at delivery (94%) and throughout breastfeeding (95%).

MTCT rates were low at delivery and during breastfeeding in all three treatment groups and did not differ significantly between the two randomized groups. Among women taking abacavir, 3 had infants infected in utero and 2 infected their infants during breastfeeding (1.8% total). Among women taking lopinavir, only 1 HIV transmission occurred, in utero (P = 0.53 versus the abacavir group). Among women taking nevirapine, 1 transmitted HIV in utero. The overall transmission rate was 1%.

Only 2% of women taking abacavir or lopinavri had treatment-limiting side effects, compared with 11% taking nevirapine. But the higher side-effect rate in the nevirapine group could reflect their more advanced HIV infection when the study began.

Overall, 71% of women breastfed for more than 5 months, but fewer than 1% continued beyond 6 months. Infant mortality was 2% in the abacavir group, 3% in the lopinavir group, and 4% in the nevirapine group.

Abstract WELBB101





IAS HALL





IAS HALL









Track B
Daily summary
22 July (Wednesday)

Today [Wednesday, July 22nd] was the last day of the conference and without doubt the most important one. The CIPRA HT 101 study was presented. This study demonstrated that starting patients on antiretroviral therapy while their CD4 is between 200 and 350 cells/mm3 both decreases mortality and the incidence of tuberculosis. This study ends the discussion on when to start antiretroviral therapy in the developing world, and should have a profound impact on antiretroviral policies around the globe. If you have to take 1 presentation from the whole meeting this should be the one. I have no doubts that you will see this study published in the New England Journal very soon. The main question now is how we implement these changes in recommendations for the initiation of antiretroviral therapy in a world in the middle of a huge economic recession.


VA Cohort: Nonsignificant Association of Abacavir Exposure With Acute MI, Further Reduced by Controlling for Chronic Kidney Disease
Posting Date: July 22, 2009

Retrospective cohort study

Summary of Key Conclusions:

Cumulative abacavir exposure associated with marginal nonstatistically significant increase in risk of acute myocardial infarction (AMI) and cerebrovascular accidents (CVA).

Association further attenuated by adjusting for presence of chronic kidney disease prior to therapy initiation or traditional cardiovascular risk factors
No association found between inclusion of abacavir in last regimen and AMI and CVA events.

Chronic kidney disease associated with significant increase in AMI and CVA
Abacavir use more common in patients with chronic kidney disease

- N = 19,424 patients enrolled
- Mean age at study entry: 46.2 (± 10.2) years
- Total patient follow-up: 76,376 patient-years
- Mean: 3.93 years/patient (range: 0-9)
- Antiretroviral exposure ≥ 30 days: 80%
- Mean antiretroviral therapy duration: 1.93 years (range: 0-8.64)


Substudy Finds No Antiretroviral Class Effect on Long-term Changes in Bone Mineral Density
Posting Date: July 22, 2009


Substudy of randomized SPAR trial

Summary of Key Conclusions:

No significant differences in changes in bone mineral density (BMD) through 144 weeks between patients assigned to a NRTI-sparing regimen or a PI-sparing regimen.

BMD declined during first 24-48 weeks after initiation of HAART, stabilized thereafter.

Investigators suggest that initial BMD decline possibly associated with delayed reversal of bone loss prior to HAART and/or may reflect a transient state between bone resorption and bone formation.

Low baseline CD4+ cell count significant predictor for early BMD loss at spine and hip.


For more detailed info (cut-and-paste):

http://www.clinicaloptions.com/hiv/conference%20coverage/cape%20town%202009.aspx


SUBMISSIONS / QUESTIONS: paulk@bcpwa.org / (604) 646-5309

Wednesday, July 22, 2009

2009 INT'L AIDS SOCIETY CONFERENCE - SOUTH AFRICA - DAY 3

Genetic Test Predicts Response to Maraviroc in Treatment-Experienced HIV Patients
Vancouver, British Columbia, Canada, July 22 2009 – A genetic approach to determining HIV tropism can be used to effectively identify patients who will respond to treatment with the CCR5 antagonist maraviroc, according to new data presented today at the 5th International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, South Africa.
Using screening samples from patients enrolled in the maraviroc treatment-experienced clinical trial program, results of this retrospective analysis showed that changes in HIV viral levels and the percentage of patients who achieved undetectable viral loads were comparable between those patients tested with HIV V3 Genotyping and Trofile™ (the recombinant-phenotypic assay originally used in the clinical trial program), indicating comparable accuracy of both tests at identifying treatment-experienced patients that will respond to treatment with maraviroc.
“HIV V3 Genotyping shows promise as a significantly faster and more cost-effective way to correctly identify patients who would benefit from CCR5 antagonists like maraviroc,” said Richard Harrigan Ph.D., lead investigator and Director of Research Laboratories, B.C. Centre for Excellence in HIV/AIDS, Vancouver, Canada. “Since the genotypic test is based on methods that are already widely used through the same labs that provide HIV drug resistance testing, this approach could become broadly available and conducted at the same time as resistance testing to determine susceptibility to all drugs, including maraviroc.”

____________________________________________________________________-


22 July 2009, Cape Town, South Africa –
The International AIDS Society (IAS) today announced the selection of Rome, Italy as host of the world’s largest open scientific conference on HIV/AIDS – the 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2011) – to be held from 17 - 20 July 2011 at the Auditorium Parco della Musica. The event will be organized by the IAS, in partnership with Istituto Superiore di Sanità (Italian National Institute of Health), which is the leading technical and scientific body of the Italian National Health Service.




High-risk genital wart strains increase HIV risk
Infection with one or more of the strains of human papilloma virus (HPV) associated with anal and cervical cancer increases the risk of contracting HIV.

Researchers from the Orange Farm circumcision study gathered information on the HPV infection status of 1683 men.

They found that the men infected with high-risk HPV strains were 4.5 times more likely than men without HPV to contract HIV.

Infection with low-risk HPV strains was not, however, associated with an increased risk of infection with HIV.




Once-daily Kaletra safe and effective in treatment-experienced patients

Previously treated patients can achieve good outcomes with once-daily lopinavir/ritonavir (Kaletra), and boost their adherence.

Kaletra is approved for once-daily dosing in combination with other antiretrovirals for individuals starting HIV treatment for the first time.

Researchers wanted to see how well this treatment strategy performed in patients with previous experience of antiretroviral therapy.

The study involved 600 people currently taking HIV treatment, but with a viral load above 1000 copies/ml. They were randomised into two equal groups, one taking the standard twice-daily dose of Kaletra (lopinavir/ritonavir 400/100mg), the other a once-daily dose (lopinavir/ritonavir 800/200mg).

After 48 weeks, equal proportions of patients in the two arms (52% vs 55%) had an undetectable viral load (below 50 copies/ml), the goal of antiretroviral therapy. Increases in CD4 cell count were also comparable between the two groups.

An advantage of once-daily dosing was better adherence.




New integrase inhibitor looks good in early clinical trials

Glaxo SmithKline’s experimental second-generation integrase inhibitor GSK-572 has performed well in early clinical trials.

In a phase 2a, ten-day, study, 35 HIV-infected, treatment-naive people were randomised to receive either monotherapy with the drug or a placebo.

Significant falls in viral load were observed in patients taking all doses of the drug. Within 2 weeks, a 2.46 log drop in viral load, from baseline, was seen in this monotherapy arm. As well, there appears to be a significantly long half-life. To this point, there appears to be no cross-resistance with raltegravir or elvitegravir.

Especially good results were achieved by individuals taking the 5mg dose, with 70% having a viral load below 50 copies/ml at the end of the study, and 90% a viral load below 400 copies/ml.

The most commonly reported side-effects were diarrhoea, tiredness and headache. With the exception of headache, these were more common in the placebo arm.

The 50mg dose will be studied in a 24-week phase IIb trial starting later this month, followed, hopefully, by a phase III trial.

5 abstracts, either oral or poster, were to be presented at this Conference.




Science has paid insufficient attention to gender identities
(masculinities and femininities) and as a result has failed to
consider the meanings and social context underlying risky
sexual practices. Dr. Jewkes is Director of the Medical
Research Council’s Gender and Health Research Unit in
Pretoria, South Africa. Dr. Jewkes’ ethnographic and epidemiological
research on gender and sexuality includes the
evaluation of Stepping Stones, an HIV prevention programme
that aims to improve sexual health by using participatory
learning approaches to improve knowledge, risk awareness
and communication skills. The research shows reductions in
new herpes simplex type 2 (HSV-2) infections and men’s use
of violence against women. According to Dr. Jewkes, the
consideration of sexual practices within a broader context of
gender identities may help explain why efforts to change
isolated sexual behaviours (such as promoting consistent
condom use) have met with resistance, and may also explain
the relatively greater success of interventions that have
sought to change gender norms.




Have HIV Programmes
Strengthened Health Systems?

Yes. At a two-day pre-conference meeting, one-hundred
health systems and HIV researchers examined existing
evidence on this crucial question and found that HIV
scale-up has enhanced and strengthened key components
of health systems:

1. Health expenditures have increased.
2. The overall health workforce has become more
innovative.
3. Human rights, social determinants and issues of
equity are now at the forefront of primary health care.
4. There is global solidarity around the need for
strengthened health systems.
5. Accountability and effectiveness of public health
programmes and services has improved.

While scale up of HIV treatment has enabled the building
of emergency systems to put large numbers of people on
antiretroviral therapy, HIV programmes must now evolve to
allow for management of HIV as a chronic health condition.
Building integrated health services for broader health
outcomes for people living with HIV is also crucial. Participants
agreed that health systems research can demonstrate
how to improve social health insurance, programme
effectiveness, and build up and retain the health workforce.



Track B
Daily summary
21 July (Tuesday)
________________________________________
Under the title of “Old Doors Closing, New Doors Opening” important new data from clinical trials was presented today. We will particularly highlight the 96-week follow-up data from the MERIT study (as observed at Week 48, when patients were reclassified according to the enhanced tropism assay, maraviroc virologic response was non-inferior to the comparator arm) , the next generation once-daily integrase inhibitor from GSK (following a 10-day administration in ART-naïve subjects, there was a significant dose-response effect, with 70% of patients becoming undetectable with the highest dose of 50 mg) , and the MONET trial (treatment simplification from Truvada/Darunavir to Darunavir alone achieved equivalent virologic response to Truvada/Darunavir continuation), this strategy could be associated with significant cost savings. A more detailed summary of these important studies, some of which have the potential to change practice, can be found in the corresponding reports of the session.
Another session highlighted significant differences in the spectra of causative microbiologic organisms in bacterial infections between HIV-positive and HIV-negative populations in both high- and low-income countries. For instance, unlike HIV-negative patients, Streptococcus pneumoniae appears to be a significant cause of bloodstream infections in Spain and of pulmonary infections with high rate of drug resistance in Uganda.
There was a very good symposium on antiretroviral resistance that discussed recent data from the resistance meeting that took place in Florida in June. Another presentation did an update on resistance from the developing world and the different pathways of resistance that the different clades of the virus can take; an issue that can become relevant in the management of patients with HIV in the South. Finally Dr. Boup made a presentation about the peculiar patterns of resistance of HIV-2.

Community
Daily summary
21 July (Tuesday)
________________________________________
Daily Summary
Tuesday July 21 2009
Dr Wafaa El-Sadr from the US expressed her major concern that countries of the North are starting to think that HIV is not an emergency anymore when only one third of the people who need treatments are getting it. HIV is a chronic disease that requires major adaptation to the health systems of countries to treat it effectively but here will be gains in treating other infectious diseases and other diseases generally if we provide enough resources to get HIV right. It is unacceptable to reject HIV-positive pregnant women who arrive at clinic needing care, or to reject HIV-positive children when it known that the chances of their dying without treatments will be around 50%.
The community engagement tour has been a highlight of the Conference for me so far. MSF plays a wonderful role in these health care settings despite huge obstacles. They provide integrated care for thousands of people living with HIV and TB who attend the daily clinics here. The challenges they face though are enormous with a scarcity of human resources caused by the difficulty to retain clinical staff on such low salaries: as someone explained to me some of the health care workers could receive higher wages working in an hotel in Cape Town than they can at their facilities. But many do the work because of the huge need and the knowledge that they are helping to keep people alive by delivering the best clinical care that is possible. It was confronting to see the numbers of children being cared for by their grandmothers and aunts as they have lost their parents to HIV.

________________________________________________________________
A mathematical model from the Harvard School of Public Health, based on the population of Washington, DC has found that recalling every adult for annual HIV screening and treating every HIV-positive person with antiretrovirals as soon as they were diagnosed would result in a 30% decline in the proportion of the HIV positive population who had non-suppressed viral loads (defined as over 500 copies/ml in this study), in the event of realistic takep of tests and treatment.
________________________________________________________________
Two studies using new methods to detect changes in arteries that could give rise to cardiovascular disease have generated differing results.
In one, a study using a sensitive ultrasound test found that long-term HIV infection was independently associated in men with an impairment of the artery’s ability to expand, with higher systolic blood pressure as the result. However, this impairment was only seen in men who had had HIV for more than 15 years.
In the other study, researchers found an apparent effect on heart function in patients who had only been on antiretroviral therapy for a month. They used a sophisticated series of PET and CT scans to map coronary perfusion – blood flow through the coronary arteries and into the heart muscle. They found there was a 31% reduction in coronary blood flow in patients taking HIV therapy when subjected to maximum cardiac stress.
________________________________________________________________________
Track B
Session summary
WESY2, Challenges in Treatment and Care
________________________________________
Powderly discussed the issue of when to start ART in patients with advanced disease and opportunistic infections. Citing the ACTG A5164 study and the SAPiT study of the optimal timing of ART in the treatment of TB, as well as an observational study of critically ill patients in Brazil that was presented in Mexico City, he noted that there is growing evidence of a benefit of ART as soon as is possible and logistically feasible to ensure adherence and access to an unbroken drug supply in people with advanced disease and acute opportunistic infections. He noted that more data will be forthcoming on the optimal timing of ART and TB initiation, and that there may be important differences between individual OIs that require further study; for example, a small uncontrolled study of ART in cryptococcal meningitis from Zimbabwe from CROI 2009 showed a higher mortality when ART was introduced earlier.
Dr. Gallant summarized approaches to second-line antiretroviral therapy by discussing when to switch therapy. Earlier switches are associated with better outcomes, as resistance develops in the face of even low level HIV replication. In resource rich settings the typical sequential treatment algorithm for patients with virologic failuare after starting on 2 NRTIs and an NNRTI is to switch to a second line regimen constructed around a boosted PI. Data suggests that a boosted PI alone may be potent enough for many patients. Continued use of 2 NRTIs is most commonly used, but there are options to use a new agent such as raltegravir, maraviroc, or etravirine. For patients initiated on a boosted PI combination, a single M184 mutation is the most likely resistance pattern that would be encountered with virologic failure. Second options for such patients include continued boosted PI therapy and other NRTIs with enhanced adherence recommendations, or a boosted PI with another active drug in the NNRTI, CCR5 inhibitor, or integrase inhibitor classes. In the developing world second line options differ. The response to the initial combination is similar in developed and developing countries. However, the use of CD4+ count or clinical monitoring to gauge when to switch therapy will likely result in a delay in treatment modification until a time when the virus has more resistance than what would typically be encountered in the developed world. Many patients failing first line therapy in the developing world have virus that is so resistant there may not be remaining NRTI options. The typical second approach is to use two other NRTIs, that have not been used previously, plus a boosted PI. An important change to ART treatment patterns in the developing world should include avoidance of thymidine analogs because of toxicities and the propensity to develop cross resistant virus after failure. The availability of viral load monitoring is essential to make wise decisions. Finally, in a general context there is a need to bridge the gap between patterns of therapy in the developed and developing world.


Track B
Session summary
WELBB1, Late Breaker B

Dr. Squires presented the 84 weeks results of a simplification trial to test the effectiveness of an unboosted PI regimen in patients with virologic suppression. Subjects (n=515) who entered the trial started on ABC/3TC + boosted ATV, were treated for 36 weeks, and were randomized to continue therapy (n=209) or drop the RTV and continue on ABC/3TC + ATV (n=210) if their viral load was <50 c/mL prior to week 36. The primary endpoint was the proportion of subjects with VL<50 c/mL at week 84 by TLOVR analysis. Subjects were predominantly White (63%) and men (84%), with a median viral load of 5.05 log and CD4+ count of 200. At week 84, 86% of subjects on ATV and 81% on ATV/r had viral loads <50 c/mL (-5%; 95% CI -1.75, 12.48, p=0.140). Similar results were seen in subjects with baseline viral loads < or >100.000 c/mL. CD4+ count changes were similar in both groups. There were a total of 8 virologic failures, 1 in the ATV group and 7 in ATV/r group, and treatment emergent mutations was seen in the one failure in the ATV group (M184) and no mutations in the ATV/r group. Treatment related adverse events included grade 2-4 hyperbilirubinemia (14% in the induction phase and 4% in the maintenance phase in the ATV arm versus 12% in the induction phase and10% in the maintenance phase in the ATV/r arm. Decreases in total and LDL cholesterol and triglycerides were observed following discontinuation of RTV in the unboosted ATV arm. In conclusion, unboosted ATV had comparable activity with less hyperbilirubinemia and a more favorable lipid profile than continued boosted ATV.
________________________________________________________________________

Dr. Gandhi's study examined the potential of treatment intensification to reduce low level, detectable viremia in patients with quantifiable viral loads <50 c/mL to determine if this low level viremia represents replicating virus or virus release from latent reservoirs. Subjects received raltegravir or placebo for 12 weeks, and then crossed over to the alternative experimental arm and followed until week 24. The study included subjects with baseline VL >100,000 c/mL and had a screening VL>1 c/mL. 125 subjects screened 60% with detectable VL, 53 were enrolled, and 49 contributed data. The median viral load of subjects was 1.7 c/mL. There were no differences between the absolute or change in viral load between the two groups or following the switch to the alternative treatment. There was a trend towards a higher CD4+ count following the addition of raltegravir that reversed after its withdrawal. These data argue against the hypothesis that ongoing cycles of replication are the main source of residual plasma viremia.


Community
Session summary
TUSY3, New Strategies and Controversy in HIV Testing and Surveillance
________________________________________
TUSY3 New strategies and controversy in HIV testing and Surveillance
Tuesday 21 July 14.30 – 1600


HIV testing and surveillance issues are becoming an increasingly critical aspect to many of the emerging debates about not only testing and treatments access, but also the appropriate focus of service delivery. Covering the increasing use of surveillance surveys – not just for collection of prevalence data, but also now including a number of other features such as CD4 levels, and incidence data, the question was repeatedly posed as to whether the cost and data burden of these large country wide survey programmes are really going to be measured as justifiable or cost effective.

The speakers agreed that current tools are not only imperfect, but as has been spoken about in other sessions at this meeting, it is also apparent that we often do not have the right tools to know if interventions being rolled out are working. As Maestro from the US observed, the most critical measure of a HIV epidemic – the incidence of HIV – is the target for many efforts from the WHO and others to develop new tools that can guide the next billions of dollars to be spent in the HIV response.

Lo from Germany also spoke to the data we do have which shows what large behavioural impact there is when people who receive counseling and testing know their status. She pointed to data that underlined this not only for those who are HIV positive, but also those in serodiscordant relationships.The power of community based interventions to increase testing, but that are linked to treatment and care services, and target also the decreasing of discrimination, were highlighted.

Finally, Amon from Human Rights Watch in New York gave a powerful overview of the the testing issues for those “hard to reach populations”. In his opening remarks it was framed that there was really no easy group, but that clearly marginalized populations were a focus – highlighting MSM, prisoners, and migrants. The criminalization of sexuality, the segregation and neglect of many in prison settings, and the discriminatory laws and policies in place around the world that deny rights to migrant populations were all described. Amon argued that unless human rights were set as the context for these problems then structural barriers for testing and treatments would continue. Government leadership and cross sectoral responses beyond only the health sector were emphasized as the only way forward.

Track B
Session summary
WEBS1, Hepatitis B and C
Pointing out that the availability of the HCV replicon has made it easier to identify HCV treatment target and assess responses, Bhagani first gave an overview of the substantial HCV drug pipeline which includes protease inhibitors (the closest to the market being telaprevir and boceprevir), polymerase inhibitors, entry inhibitors and others such as immune modulators. He however pointed out that many questions remain including how the findings apply to HIV-infected patients (as no study involved HBV/HIV co-infected patients), potential emergence of resistance and drug-drug interactions. He then drew attention to the new epidemic of acute HCV infection among MSMs which has spread beyond Europe. In concordance with what Lewin discussed earlier, he pointed that progression to end-stage liver disease has improved in the HAART era, but remains significantly higher in HIV/HCV than HCV-only patients. Also, better control glucose metabolism is associated with improvement in liver fibrosis in HIV-infected patients.
The speaker then went on to outline factors predictive of clinical response to HCV, including acute infection, low viremia, younger age, lack of stage ¾ fibrosis or steatosis, ethnicity, low BMI, high CD4 and lack of insulin resistance. Finally he discussed potential strategies to maximize treatment response. We’ll highlight that longer duration of undetectability on treatment increases chance for SVR, which is why the current guidelines total duration of HCV treatment depends on the speed of achieving undetectability. Increasing the interferon dose did not alter the response rate.
Finally, regarding HBV, he highlighted the importance of lamivudine resistance on disease progression, and the caution about the efficacy of entecavir on HIV replication.

Rapporteur report

Track B report by Ian Frank, Pablo Tebas, Renslow Sherer and Roger Bedimo

In a substudy of the GRACE trial of boosted darunavir in antiretroviral naïve women, changes in immunological markers following therapy were described in 19/32 virologically suppressed subjects. CD4 counts increased 195 cells/mm3 at week 48. Decreases in percent CD38+DR+CD4+ and %CD38+DR+CD8+, markers of immune activation towards, but not to control levels seen in an HIV uninfected control group were seen. Functional recovery, as assessed by capacity to proliferate and the expression of intracellular cytokines by CD4+ cells, was observed.
The TRIO study evaluated open label raltegravir, boosted darunavir, and etravirine in highly treatment experienced patients. 103 subjects were enrolled with a baseline viral load of 4.0 log10 c/mL, a median CD4+ count of 255, and 13 years of treatment experienced. The proportion of subjects with viral loads <50 copies/mL at weeks 24 and 48 were 90% and 86% respectively, demonstrating the durability of the response.
Trottier and colleagues analyzed the contribution of NRTIs to a salvage combination in highly treatment experienced patients who received raltegravir, maraviroc, etravirine, and NRTIs. There were no active NRTIs by genotype. There was an inverse correlation between number of NRTIs prescribed and probability of achieving a viral load <50 c/mL. [This information was presented similarly at CAHR 2009 – Vancouver]


IAS 2009: The Numbers

• 5,80+ participants
• 360 volunteers
• 1,000+ Facebook fans
• 123 countries represented
• 197 scholarship recipients
• 299 media representatives
• 2,400+ abstracts submitted,
with 1,550+ accepted
• 59 total sessions
• 12 plenary speeches
• 5 special sessions
• 49 exhibits
• 35 satellite meetings
• 6 scientific awards

Tuesday, July 21, 2009

2009 INT'L AIDS SOCIETY CONFERENCE - SOUTH AFRICA - DAY 2

As promised, here – again – is a summary of some main events occurring in Capetown, South Africa, at the International AIDS Society’s 2009 5th Conference on HIV Pathogenesis, Treatment and Prevention. The Conference concludes on Wednesday, July 22nd.

It is always difficult, and is a necessarily subjective process, to cull from various sources and limit the detail while offering such coverage.

Today’s Newsletter is longer; however, please note it contains more scientific content… The opening day’s content is more announcement-like.

Again, the official sources for this information (as suggested by the Conference organizers) are:

- The Live Conference Blog
- News Releases
- Facebook
- twitter
- Clinical Care Options
- Rapporteur summaries

For more in-depth information on these and other subjects arising from this Conference, please visit: http://www.ias2009.org/


This Newsletter summary will continue daily through and including Thursday, July 23rd.




MAIN HALL




MAIN HALL (CLOSE UP OF STAGE)



PLENARY HALL


Biomedical Prevention – Microbicides, Vaccines, Circumcision and PrEP

In his plenary presentation, Dr. Ronald Gray summarized the results of the 28 completed biomedical HIV prevention trials of STD control, microbicides, pre-exposure prophylaxis (PrEP), HIV vaccines and male circumcision. Of these trials, only four, including three of male circumcision, have reported significant efficacy. According to Dr. Gray, one of the
1 2
conclusions to be drawn from positive and negative results is that phase III prevention trials are difficult, expensive and time-consuming. Ultimately, according to Dr. Gray, researchers will need to more carefully screen candidate interventions prior to trials and may need to conduct fewer trials, but with a greater investment in rigor and quality. Dr. Gray is Robertson Professor of Reproductive Epidemiology in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.



ELITE CONTROLLERS
People with AIDS may have viral loads of several hundred thousand copies per milliliter. In contrast, the viral loads of elite controllers range from a scant 50 down to levels so small that even the most sensitive tests can't detect them. Doctors know these people have the virus only because separate tests have revealed the presence of antibodies to HIV in their systems. In other words, elite controllers aren't HIV-free; they may still be able to pass the virus to others, in whom it may be deadly.
Early on, researchers discovered that elite controllers aren't infected with a less virulent strain of the disease. But little else about their condition is certain.
Since 2006, Walker and his colleagues have been organizing an international contingent of more than 250 researchers and more than 200 physicians who have elite controllers as patients. Initially funded by a gift from the Mark and Lisa Schwartz Foundation and recently boosted by a $22 million grant from the Bill & Melinda Gates Foundation, the International HIV Controllers Study is working to identify elite controllers, collect samples of their blood and DNA, and distribute the samples to labs for analysis.
Vaccines normally work by introducing a dead or harmless piece of virus that stimulates the adaptive immune system to attack. In that way, the body builds defenses capable of destroying the real virus. But AIDS has resisted every effort to develop a vaccine.
The MIT team wants to know whether the T cells in elite controllers have special properties. The answer will require a much more detailed understanding of how T cells function. So the team has developed a system to trap a single T cell along with a single cell infected with HIV. That allows researchers to watch T cells attacking infected cells and to compare the action of elite controllers' cells with those of patients whose HIV has progressed into AIDS.
One clue may already have emerged. In the Dec. 19 issue of the journal Immunity, researchers at the National Institute of Allergy and Infectious Diseases concluded that the killer T cells of elite controllers killed 68 percent of infected cells in an hour, compared with just 8.1 percent for those with AIDS.
One theory about elite controllers holds that they possess special genetic traits, beyond any differences in their immune systems, that better equip them to battle AIDS. Geneticist Paul de Bakker of Brigham and Women's Hospital in Boston is combing through the human genome to find those characteristics. It's a daunting endeavor. The genome comprises 3 billion coded pieces of information that determine who a person is. Some 99.9 percent of these pieces are the same in all people, but there are points of difference known as single nucleotide polymorphisms (SNPs, pronounced "snips").


GRACE Shows Similar Treatment Response Rates in Women and Men on Prezista Treatment
July 20, 2009
By Tim Horn
Long-awaited 48-week data from the Gender, Race and Clinical Experience (GRACE) study indicate that Norvir (ritonavir)–boosted Prezista (darunavir) can be used in women and men with similar safety and efficacy outcomes. Reported by Kathleen Squires, MD, of Jefferson Medical College in Philadelphia and her colleagues on Monday, July 20, at the Fifth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, GRACE also documented higher rates of study discontinuation among women, underscoring the need for further investigation into ways to better retain women in clinical trials.

Prezista, combined with low-dose Norvir, has been approved in the U.S. as a protease inhibitor option for treatment-experienced patients, as well as first-time treatment takers and HIV-positive children between the ages 6 and 17.

About 66 percent of the women enrolled were black, compared with 51.4 percent of the men. Hispanics/Latinos accounted for 20.9 percent and 25.4 percent, respectively. The average length of infection upon entering the study was about 11 years; in addition, 58.5 percent of the women and 64.8 percent of the men had used at least two protease inhibitors before enrolling in GRACE. Average CD4 counts at study entry were 210 cells in the women, compared with 175 cells in the men.

The rate of treatment discontinuation was higher in women (32.8 percent) compared with men (23.2 percent). This difference was statistically significant, meaning it was too great to have occurred by chance. The primary reasons for study discontinuation were loss to follow-up and side effects; however, there were no trends toward a specific type of side effect driving discontinuations in either group.

Men experienced a slightly better CD4 cell recovery compared with women after 48 weeks in the ITT analysis: gains of 89 versus 68 cells, respectively. But in the less stringent analysis, women faired better with a 131 CD4 cell gain, compared with a 104 cell gain among men.

The number of men and women who developed new HIV resistance mutations while participating in GRACE was small, according to data still being analyzed. Two (7.4 percent) women, compared with two (1.2 percent) men, were found to have a new major protease inhibitor-resistance mutation after experiencing virologic failure.

Overall, 90.2 percent of the women and 83.1 percent of the men experienced at least one adverse event, the majority of which were mild-to-moderate in severity. In total, 46.7 percent of women and 43.0 percent of men experienced at least one adverse event considered by Squires’s group to be at least possibly related to the use of Prezista/Norvir.

The most common side effects were nausea (24.4 percent of the women versus 14.1 percent of the men), diarrhea (16.4 versus 22.5 percent, respectively), upper respiratory tract infections (11.1 versus 7.7 percent, respectively) and vomiting (11.5 percent versus 6.3 percent). Interestingly, serious adverse events were less common among women compared with men: 16.4 percent versus 22.5 percent, respectively.

In conclusion, Squires pointed out that the GRACE study successfully enrolled a high proportion of women and is, to date, the largest North American study to assess sex-based differences in the efficacy and safety of an ARV regimen. Overall, she said, the data reported suggest that Prezista/Norvir can be used in women and men with similar safety and efficacy outcomes.


DART study

A major study has shown that HIV treatment can be successful in resource-limited settings without laboratory monitoring.

The DART study involved over 3300 adults in Uganda and Zimbabwe. All were starting HIV treatment for the first time.

Half the patients were randomised to change to second-line antiretroviral therapy if their CD4 count fell, the others switching if they developed a serious HIV-related illness.

Similar proportions of patients in the clinical monitoring arm (87%) and laboratory monitoring arm (90%) were alive after five years.

There were no differences in toxicity rates between the two arms.


Direction of Obama government HIV policy

Presentations from senior US HIV officials have given some clues about the priorities of the Obama administration.

These include:

Continued PEPFAR funding
Earlier HIV treatment
Exploring the concept of 'treatment as prevention'.




Abacavir and heart attack: debate continues

Two new studies have found no connection between treatment with abacavir (Ziagen, also in the combination pills Kivexa and Trizivir) and an increased risk of heart attack.

The first study involved over 19,000 US veterans with various HIV treatment histories. The first set of results showed that abacavir was associated with a modest 17% increase in the risk of heart attack. But when the researchers controlled for other risk factors, this association was weakened.

Of note, the investigators found that patients with kidney disease, which can increase the risk of cardiovascular disease, were more likely to be given abacavir. They believe that this could be an explanation for the association between treatment with the drug and heart attack.

A second smaller study was conducted in Spain. It involved 300 patients and showed that treatment with abacavir did not affect levels of bio-markers that can predict an increased risk of heart attack.

'Treatment as prevention' must not violate human rights
A plenary session at the conference was told that expanded HIV testing and treatment as prevention must not be coercive or violate human rights.

Mathematical models have predicted that increasing the number of individuals diagnosed with HIV and on antiretroviral therapy has the potential to significantly slow the pace of the epidemic.

But human rights organisations said that testing for HIV must not be coercive. They also emphasised the importance of having properly trained counsellors, and linking testing to treatment and education.


MORE DETAILS ON A STORY QUOTED YESTERDAY:
South Africa begins AIDS vaccine trial, cuts funds

AP – Dr Danielle Crida, left, demonstrates how a new Aids vaccine is administrated on a trail subject, Wanda …
By MICHELLE FAUL, Associated Press Writer Michelle Faul, Associated Press Writer – Mon Jul 20, 5:26 pm ET
CAPE TOWN, South Africa – South Africa launched a high-profile trial of an AIDS vaccine created by its own researchers Monday, a proud moment in a nation where government denial, neglect and unscientific responses have helped fuel the world's worst AIDS crisis.
After a government official lauded the project at a ceremony at Cape Town's Crossroads shantytown, the scientist leading the research said state funding had been halted.
The contrast between Monday's hopeful vaccine launch and the revelation of funding cuts raised questions about whether the government was backsliding on its pledge to combat AIDS.

Anna-Lise Williamson, an AIDS researcher at the University of Cape Town, told The Associated Press the clinical trial would continue with U.S. money. But she said South Africa's Department of Science and Technology had pulled its funding in March, while the project's other sponsor, the state electricity utility Eskom, did not renew its contract when it expired last year.

Neither government spokesmen nor Eskom immediately returned calls seeking comment about funding cuts.

The South African vaccine was developed at the University of Cape Town and targets the specific HIV strain that has ravaged South Africa. It is also undergoing safety tests at a trial involving 12 volunteers in Boston that began earlier this year, said Sarah B. Alexander, spokeswoman for the HIV Vaccine Trials Network at the Fenway Institute, an AIDS treatment center where the trial is under way.

The safety trials started in the U.S. to allay any criticism the United States was collaborating on an AIDS vaccine that might be seen as using Africans as guinea pigs, she said.

In its vaccine initiative, the government decided it was important to target the HIV subtype C strain that is prevalent in southern Africa "and to ensure that once developed, it would be available at an affordable price," said Anthony Mbewu, president of South Africa's government-supported Medical Research Council, which shepherded the project.

Some 250 scientists and technicians worked on the vaccine's development.
Dr. Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Disease and a leading AIDS researcher, was in South Africa for the trial launch and said the South African scientists received more money from his institute's research fund than any others in the world, outside the United States. The U.S. also paid to produce the vaccine.

He called it "the most important AIDS research partnership in the world."
But, he warned: "There are extraordinary challenges ahead," referring to the years of testing needed now that South Africa has reached the clinical trial stage.
Monday's launch was put on by the South African AIDS Vaccine Initiative, the lead program of the government-backed Medical Research Council. The deputy ministers of health and science were both at the event and praised the initiative.

Aaron Motsoaledi, a medical doctor who became health minister in May, has promised to try to strengthen AIDS prevention campaigns that were weakened for years by red tape and mixed messages from policy makers.

Getting people onto treatment, not earlier treatment, must be priority, conference warned
Monday, July 20, 2009 2:00 AM
Filed under: Conference news, Starting treatment news, IAS 2009
Debates about whether to start treatment at a CD4 count of 350 in developing countries ignore the fact that current programmes are doing very badly at retaining patients in care after diagnosis or starting people on treatment before they become seriously ill, Dr Francois Venter, President of the South African HIV Clinicians Society told the Fifth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention on Monday.
Speaking during a conference symposium on when to start treatment, Dr Venter pointed out that the current average CD4 count at which patients start treatment in South Africa is 87 cells/mm3.
Despite a huge increase in the number of people who undergo HIV testing – up to one-quarter of South African adults took a test in the past year, according to 2009 research by the Human Sciences Research Council – the average CD4 count at which patients in his Johannesburg clinic start treatment has not moved above 80 to 100 cells since 2004, Dr Venter said.
“We are still doing a terrible job of retaining patients in care, and we need to start looking harder at retention in care,” he said. “Are you delivered into a package of care that looks after you [after diagnosis]?” he asked.
A large number of patients were dying while waiting for the results of diagnostic tests and while undergoing treatment-preparation counselling, or during acute opportunistic infections.
He also expressed concern about the implications of recent findings on the inflammatory effects of HIV infection for developing countries. “Cardiovascular disease is not usually seen as an African problem, but death-certificate analysis in South Africa recently revealed that diabetes and hypertension were among the most frequent causes of death.”
Similarly, South Africa is seeing overlapping epidemics of HIV and obesity. Potent cardiovascular risks may lead to a high rate of cardiovascular disease in people with HIV, Dr Venter argued. He also drew attention to the high rate of liver disease and hepatitis virus infection in the developing world, to data showing that uncontrolled HIV replication exacerbates liver damage, and to the high frequency of kidney disease in African-Americans with advanced HIV infection (people of African origin appear to have a high risk of HIV-associated kidney damage).
“The thing that filled me with fear [looking at the data on inflammation and HIV] was renal disease. Kidney transplants, dialysis, even prophylactic drugs to deal with proteinuria are difficult to obtain and expensive in this region.”
Eighty-four per cent of maternal deaths and 47% of postnatal infant infections occur at CD4 counts below 350, he noted.
“… one of the major obstacles to early treatment in the developing world is the current reliance on d4T (stavudine) in first-line treatment.
Starting treatment in the developed world
In the developed world national US, British and European guidelines now concur that treatment should be recommended to all patients with CD4 counts below 350.
While US cohort data suggest benefits to starting treatment before the CD4 count falls below 500, another major cohort analysis did not find an additional benefit to starting treatment at CD4 counts above 400, and an international randomised trial called START is currently recruiting patients to determine whether starting treatment at a CD4 count above 500 results in less death and illness than starting at the currently recommended threshold.
Dr Jose Gatell of Hospital Clinic, University of Barcelona, highlighted that current European AIDS Clinical Society treatment guidelines state that antiretroviral treatment should be considered for all diagnosed patients.
He warned “We cannot wait until completion of the START study to make decisions.”
But to achieve an extended period of healthy life, normalisation of CD4 counts needs to be achieved. Professor Gatell pointed to research showing that normalisation of CD4 counts for at least five years above 500 cells is necessary in order to eliminate the difference in mortality between people with HIV and the general population.
Nevertheless, a substantial proportion of patients continue to fail to reach this CD4 level with current treatment due to late initiation of treatment, he noted. Therefore all patients with a CD4 count below 350 should be offered treatment unless there is a specific contraindication.

RAPPORTEUR:
Track B
Session summary
MOAB2, Cardiovascular Disease: to HAART or not to HAART
________________________________________
Not surprisingly the session started with presentations related to the presumed role of abacavir in increasing the risk of cardiovascular events in patients with HIV infection, a topic that has been in the mind of clinicians, patients, and researchers since the original presentation of this data by the DAD group in 2007.

Bedimo et al. presented a large epidemiological study of the VA cohort that included more than 19000 participants. In this cohort the use of abacavir was marginally associated with an increased cardiovascular risk, and the association disappeared after adjusting for traditional risk factors, renal function (the main reason ABC is used instead of tenofovir) and HCV. Importantly, renal dysfunction was an additional strong predictor of cardiovascular risk.

RAPPORTEUR:

Track B
Session summary
MOSY3, Current Issues in Pharmacology and Toxicology
________________________________________
Carr gave an update on changes of body composition (fat and bone) and their importance in the management of HIV infected individuals. The discontinuation of thymidine analogs consistently (and slowly) improves lipoatrophy, one of the most feared toxicities of HIV treatment. Tesomorelin decrease fat in patients with fat accumulation, but its benefits are transient. Bone is affected probably by all ART regimens, with bone loss after the initiation of therapy that is greater with some drugs (TFV). Although tenofovir appears not to decrease kidney function at the population level, once renal problems appear in a particular individual, they are only partially reversible. Hyperlipidemia and insulin resistance are also very common in HIV infected individuals and that was the focus of Dr. Currier who discussed different lipid lowering therapies, ART switch, and intensification strategies to manage it. She also discussed the effects of HIV infection itself, and of different classes of drugs, on insulin resistance and lipids. She noted that it is necessary to address both problems to decrease the incidence of cardiovascular disease


RAPPORTEUR:

Track B
Session summary
MOPDB1, Update on Diagnosing and Monitoring
________________________________________
In this symposium on advances in point of care diagnostic testing, Wee presented an elegant micro-fluidic system which is the size of a credit card for the quantification of HIV1 cDNA for neonatal diagnosis. With a 30 minute throughput, the data correlated well with a standard table top analyzer, with an R2 value of 0.997, and is well positioned for large scale testing.
In order to improve the accuracy and precision of viral load testing in reservoirs, Fiscus et al studied the Abbott m2000 RealTime HIV-1 viral load assay, which is standardized for plasma, in breast milk, dried blood spots (DBS), seminal plasma, and cerebrospinal fluid, and compared the results to plasma. Linear results were obtained for all fluids, and, compared to blood, recovery was near 100% for semen, CSF, and DBS, and roughly 50% for breast milk.
In contrast to the earlier presentations, an independent review of various rapid tests in 20 HIV negative and 200 HIV-1 individuals specimens by Payle et al result in high rates of false negative results with oral fluid and blood specimens. The highest false negatives were seen with the Oraquick oral fluid (11.9%), with false negative rates of 3-4% for Oraquick blood and Determine rapid blood tests, and the lowest rates with the Vikia and INSTI blood tests (<2%). The authors urged awareness of this variability and caution in the interpretation of these results.

Community
Session summary
MOSY1, When to Start
________________________________________
When to Start?
Monday July 20 11am

Josep Gatell from the University of Barcelona: The data on years of survival for people on HAART who started below 350 was acceptable (at 35 years) but patients needed to be above 500 T-cells for at least 4 years to have the same life expectancy as the rest of the population. Two thirds of Gatell’s cohort start below 350 T-cells and only half of that (53%) reach more than 500 after 3 years.

(NB: Elsewhere, Gatell is quoted as saying “… at least 5 years…”)

There is also now more evidence of higher risks of AIDS defining events for those who start under 350 and more results about the role the virus itself plays in chronic inflammatory responses in people with HIV. Viral replication is a main predictor of non-AIDS events. Evidence is mounting that people should start earlier when their T-cells are less than 500. This was particularly true for people with other health issues such as a higher cardiovascular risk, Hepatitis B or C and pregnancy.

Nevirapine May Be Option for Some Kids After Single Dose for MTCT
Author: Mark Mascolini
________________________________________
20 July 2009
Children exposed to single-dose nevirapine (sdNVP) for prevention of mother-to-child transmission (MTCT) of HIV may be able to replace lopinavir/ritonavir with nevirapine in a first regimen after that regimen gets HIV replication under control, according to results of a randomized trial presented at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention.

The investigators caution that more work must be done to confirm the findings and define which children may safely swap lopinavir/ritonavir for nevirapine. But if the results hold, the strategy would be a plus in low-income countries where many children are exposed to sdNVP and still become infected with HIV. Nevirapine is cheaper and easier to use than the protease inhibitors (PIs) lopinavir/ritonavir because it is formulated into a single pill with other antiretrovirals. Nevirapine may also have fewer long-term side effects than lopinavir/ritonavir.



http://www.clinicaloptions.com/HIV/Conference%20Coverage/Cape%20Town%202009.aspx

2009 INT'L AIDS SOCIETY CONFERENCE - SOUTH AFRICA - DAY 1

As promised, here is a summary of some main events occurring in Capetown, South Africa, at the International AIDS Society’s 2009 5th Conference on HIV Pathogenesis, Treatment and Prevention. The Conference had a number of ancillary events held prior to its official opening ceremonies on Sunday, July 19th. The Conference concludes on Wednesday, July 22nd. More than 5,000 researchers, clinicians and community leaders are expected to attend the conference.

It is always difficult, and is a necessarily subjective process, to cull from various sources and limit the detail while offering such coverage.

The official sources for this information (as suggested by the Conference organizers) are:

- The Live Conference Blog
- News Releases
- Facebook
- twitter
- Clinical Care Options
- Rapporteur summaries

For more in-depth information on these and other subjects arising from this Conference, please visit: http://www.ias2009.org/

This Newsletter summary will continue daily through and including Thursday, July 23rd.


OPENING HIGHLIGHTS:

HAART as Prevention

“The added preventive benefit of antiretroviral therapy represents a compelling new rationale for the re-invigoration of HIV treatment roll-out and gives further urgency to the need to avert disruptions in access to life-saving medicines,” said IAS President Dr. Julio Montaner, who is IAS 2009 Chair and Director of the BC Centre for Excellence in HIV/AIDS in Vancouver, Canada. “By reducing HIV transmission, as well as morbidity and mortality, treatment scale up is not only the right the thing to do for humanitarian and public health reasons; it is also a cost averting intervention, which makes fiscal sense in these difficult times.”

In addition to these remarks, above, Dr Montaner also said the following:

"Earlier this month, another G8 Summit came and went. HIV/AIDS was indeed the elephant in the room. In 2009 the eight most powerful economies in the world left HIV off their priority agenda. They parted with no progress report on HIV, and they even failed to renew their prior commitments to the goal of universal access to HIV, prevention, care and treatment by 2010. This is totally unacceptable. This is a tragedy."

"HAART is no longer viewed as just a cost-effective intervention that prolongs the life of a person living with HIV or AIDS. HAART is now additionally viewed as an essential tool to curb the growth of the epidemic."

Importantly too, Montaner re-emphasised the importance of not compromising human rights (and protections for marginalised communities such as MSM, IDU and sex workers) in the process of providing treatment and care to people with HIV.


In his plenary remarks, Dr. Reuben Granich, Medical Officer for HIV/TB in the HIV/AIDS Department of the World Health Organization (WHO), examined the significant promise of the use of HAART as part of a combined approach to HIV prevention that includes behavioral, structural and biomedical prevention interventions. Dr. Granich outlined the context and basic assumptions regarding this emerging strategy, including when to start ART for maximal clinical and prevention benefit. He also highlighted the essential roles of human rights, dignity and community engagement in the use of HAART for prevention and discussed the outstanding biological, feasibility, impact and cost issues related to research in this arena [emphasis added].


HIV and Host Genetics

Dr. Amalio Telenti discussed the relatively new field of HIV and host genetics, examining the role of host genetics in susceptibility to HIV-1 disease, plasma drug levels and treatment toxicity. Dr. Telenti, Professor of Medical Virology and Director of the Institute of Microbiology at the University Hospital Center of the University of Lausanne, Switzerland noted that despite some false starts, there is now solid data in this arena, including a thorough understanding of the role of common human genetic variation in HIV disease progression and drug toxicity. He said that we can now explain 22% of population variance in viral load by genetics, population effects, gender and age. He thought that it won’t be long before there are useful predictive pharmaco-genomic strategies to predict toxicities of certain antivirals and to allow for the creation of optimal treatment regimens for individuals [emphasis added].


Prevention of Mother-to-Child Transmission

Dr. Louise Kuhn called for a mobilization of political will to implement the latest knowledge on prevention of mother-to-child transmission (PMTCT), highlighting data on breakthroughs in PMTCT strategies during breastfeeding, including lactation support and counseling, continuation of maternal HAART after delivery, and extended infant prophylaxis with nevirapine. According to Dr. Kuhn, the urgency of implementing these interventions is underscored by accumulating data on negative impacts of avoiding or shortening the duration of breastfeedign [emphasis added].

The issue of treatment as prevention is set to be a major discussion topic at this Conference and it is important one for community to monitor. Dr Reuben Granich, from the United States, began the plenary saying that if there was universal testing and immediate ART, combined with other prevention interventions, there would be a 95% reduction in HIV cases in 10 years and the incidence would be reduced from 15-20 000 to 1000 cases per million. Prevalence (or the number of people with HIV) would become less than 1% by 2050. Initial resources would be higher but this approach may provide cost savings.



Some interesting quotes:

Hoosen (Jerry) Coovadia (IAS 2009 Local Co-Chair, Chairman of Dira Sengwe and Scientific Director of the Doris Duke Medical Research Institute at the University of KwaZulu-Natal):

"HIV is the hand-maiden to tuberculosis."



Kgalema Motlanthe (South African Deputy President):

"Unless we redouble our efforts to conquer this disease it will define the 21st century for sub-Saharan Africa."



Françoise Barré-Sinoussi (2008 Nobel Laureate and IAS Governing Council):

Viral reservoirs constitute the major obstacle to eliminating HIV from the body. Prof. Barré-Sinoussi was expected to explain how HIV – hidden mostly in subpopulations of latently infected resting memory CD4+ T cells – persists by distinct mechanisms in patients treated with highly active antiretroviral therapy. In her remarks, she was to pose some of the most vexing questions facing AIDS scientists and clinicians today, including: What are the main reservoirs of HIV in the body? What are the mechanisms responsible for the establishment and persistence of these reservoirs? Which strategies can be proposed accordingly?

"There is still a very long way to go" in controlling HIV reservoirs.




Stephen Lewis (AIDS Free World Co-Director):

"When, as now, there's a backlash against funding for AIDS, with
mindless charges against AIDS exceptionalism, you should find a way collectively to shoot down the pinched bureaucrats and publicity-seeking academics who advocate exchanging the health of some for the health of others."

"We must never allow them to play one part of the health sector against the other...HIV/AIDS, for all the horrendous human consequences, has objectively strengthened health systems."

"When the G8 won't renew its 2005 commitment to universal access...then it's time for science to speak with one powerful voice of accusation."


"An ugly homophobic culture is a threat to public health that
inevitably serves to spread the virus."



Events which occurred prior to, but that are connected with, the Official Conference Program included:


IAS 2009: 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention – Treatment Action Campaign sponsored a march and rally calling for the resources needed to meet the South Africa National Strategic Plan's targets for HIV/TB treatment and prevention just prior to the opening of the conference on 19, July 2009. One of the loudest cheers went up for a doctor in the public health service who explained why doctors had found it necessary to go on strike about the lack of health care workers to do the tasks required to care for plhiv.


Viyuseka Dabula, General Secretary of Treatment Action Campaign:

“When I need second-line treatment I want a guarantee I can get access to it, “she said. “If we don’t increase the resources available, 90% of the current monies will be needed for second line treatment by 2012.”


Some photographs taken during the first few days include:



Dr Montaner – wearing the Rally shirt “HIV-POSITIVE” – signs a petition





South African Health Minister Dr. Aaron Motsaoledi asks for, and then puts on, an HIV Positive t-shirt in solidarity with activists demonstrating for increased resources for HIV and health services.



Médecins Sans Frontières (MSF) reported on disruptions in supplies of antiretroviral (ARV) drugs in six African countries. Citing the catastrophic consequences of drug shortages on new patients and those already in care, the MSF report called on national governments, donors and their partners to take swift action to address the funding gaps and supply distribution problems hampering access to lifesaving drugs. The six countries cited were the Democratic Republic of Congo, Guinea, Malawi, South Africa, Uganda and Zimbabwe.


US Global AIDS Coordinator Eric Goosby and NIAID Director Anthony Fauci spoke at an IAS 2009 special session entitled, Global HIV Research and Policy and Programme Implementation under the New United States Administration. The session was on Monday, 20 July, from 1:00 – 2:00 pm (local time) and it was chaired by Global Fund Executive Director Michel Kazatchkine.

This is the first major international AIDS conference for Ambassador Goosby, in his role as Coordinator of the President’s Emergency Plan for AIDS Relief (PEPFAR), the US government’s multi-billion dollar global AIDS programme. Dr. Fauci, who has spoken at previous IAS conferences and is always a big draw, discussed US government-funded HIV research. The session was expected to attract a standing room only crowd eager to hear details of the Obama Administration’s plans. Those unable to watch in person can access a free webcast of the session on the conference website.
Dr Fauci:

"Sure" US #HIV travel ban will be lifted. Everyone I have talked to in the Obama Admin supports lifting ban.

Wednesday, July 15, 2009

Yogurt Promotes Gut Health

Yogurt, or more specifically the bacteria in it, seems to have a positive effect on both CD4 counts, and may protect against some HIV related diseases.

A recent article in the journal Nature Magazine explores the connection between yogurt consumption and gastrointestinal health. The gut is home to over 100 trillion microorganisms that help with immunity and digestion. HIV Researchers have known since the early days of the pandemic that HIV can wreak havoc in the gut which is home to an abundance of CD4 cells (helper T-cells). It has also been known for some time that probiotics can aid in the treatment of fungal infections such as thrush.

The verdict is still out, and researchers continue to explore the symbiotic relationship that the probiotic bacteria may have. In the mean-time, Canada’s food guide suggests 2-4 servings of dairy per day, try making a yogurt with “live bacterial culture” part of your diet.

Do you experience many “gut” problems due to HIV? What do you find helps?
Until next week…be well!

Wednesday, July 8, 2009

Touch me in the Morning! A Breakfast Conversation About Research On Gay Men’s Sex.

As part of the Treatment Information Program at BC Persons With AIDS, this week’s blog is to invite you to an upcoming, informal discussion of HIV research, taking place during PRIDE.

Wednesday, July 29th from 8 to 10am.

HIV Research Cafés bridge the worlds of community and academia through casual and respectful plain language conversations about HIV research articles which we send to you in advance. Read as much or as little as your time, energy and interest permits.

It’s like friends gathering over breakfast to chat. No group presentations mentioning HIV, no talking heads, no signs saying “HIV Research”, no minutes and no recordings. Open to all interested.

We’d love to hear your input and questions regarding sex, or sex as an HIV positive individual. Do you have a hard time discussing your HIV status with your potential partners, or what other concerns may you have? Please drop us a note as they are monitored daily. Until next week…be well!


This Breakfast is by registration only!

Register with Glen Eatly at the following: cafeguest@bcpwa.org .


An event hosted by the Community Based Research Program housed at BC Persons With AIDS Society.

Wednesday, July 1, 2009

Treatment Side-effects; Skin Disorders

Individuals with HIV can develop minor skin complications when they start HAART. The most common reaction is a rash, or dry patches anywhere on the body. These problems will usually resolve themselves after your body gets used to the treatment medications.

However, there are a couple of things to keep and eye out for:

If the rash is accompanied by a fever, nausea or coughing, speak with your doctor; go to emergency if symptoms rapidly worsen, or if you have difficulty breathing.

After starting HAART, as our immune system becomes reconstituted (stronger), flare-ups of skin disorders are common, with eosinophilic folliculitis being one of the most common issues.

As dry skin can also be a problem, topical creams containing oatmeal, calendula (marigold), silicone or Vaseline should all help. Apply at least once daily, particularly after you shower.

Do you have any questions about treatment side-effects? Please drop us a note. Until next week...be well!

Wednesday, June 24, 2009

Treatment Side-effects: Sleep Disorders

Sleep is an essential process needed by the body as “down time” in order to rest and repair from the day. With person’s with HIV, side-effects of treatment may create sleeping disorders. If you are not able to get regular, good quality sleep, either in the long or short term, your ability to think, speak and concentrate will be reduced. You can become more irritable and have slower reactions, and your memory and judgment will be affected.

Try these few tips first to try and improve your sleeping, if the problem persists, please contact your health care provider.

Take a hot bath before bed
Have a cup of herbal (chamomille) tea or warm milk
Make your room a quiet and comfortable refuge; only use it for sleeping in
Try to get some exercise every day
Get into a routine where you go to sleep and wake up at the same time each day

As I mentioned, if sleeping disorders persist, you should contact your doctor as he will be able to help. What are your tips for helping to get to, or to stay asleep? We always love to hear from you. Until next week…be well!

Wednesday, June 17, 2009

Treatment Side-effects; Nausea

Most antiretrovirals, as well as many other drugs used to treat infections in those of us with HIV, list nausea and vomiting as some of the most-likely side-effects. Besides making it difficult to go “out and about”, nausea and vomiting can in the long-term cause serious problems such as dehydration and malnutrition. Here are a few tips for dealing with nausea:

-Eat small, more frequent meals
-Avoid greasy, fat, fried or spicy foods
-Herbal teas, especially peppermint, chamomile and ginger will help
-Over-the-counter drugs such as dimenhydrinate (gravol)
-Don’t lie flat for at least an hour after eating or drinking
-Eat cold food, warm food can worsen nausea

What works for you in decreasing nausea and vomiting, or is it not an issue for you? Until next week…be well!

Thursday, June 11, 2009

Treatment Side-effects: Diarrhea

Diarrhea is one of the most common side-effects of HAART, and has a huge impact on our ability to go about our days. The good news is that this side-effect does respond to treatment and can usually be managed.

Diarrhea is an increase in the water content, frequency, and volume of bowel movements. It can become a serious problem if left untreated, leading to dehydration and nutritional problems. If diarrhea has just become a problem, it may become serious, please check with your doctor if it does not clear up within a few days.

If Diarrhea is a problem, there are various ways of trying to clear it up. Over-the-counter medications such as loperamide (Imodium) may help, or prescription medications will usually do the job as well.

Another way to attack the problem is through your diet. Stay away from coffee and other caffeinated beverages, as well as spicy or fried food. The BRAT diet really helps, it consists of Banana’s, Rice, Apple juice and Toast or tea.

Do you experience many side-effects that are attributed to treatment? How do you manage them? If you have any questions regarding side-effects, please ask and we’ll do our best to answer. Until next week, be well!

Monday, June 8, 2009

HIV and Swine Flu (H1N1)

What is Swine flu and is its occurrence relevant to individuals with HIV? Swine flu is only a new strain of the flu virus that has yet to have been in contact with humans. As we have never been exposed to this flu, we do not have any antibodies to it which makes us a little more vulnerable.

Generally taking the same pre-cautions which we usually use, should avoid contracting this flu. The singular most important thing that we can do is hand washing. Other precautions involve of course staying away from those infected, and if the flu is showing up in your area, avoiding crowded places if possible.

If you develop any flu symptoms and you suspect it could be swine flu, DO NOT go to your doctor’s office as this may contribute to the spread. Instead, call your doctor and they will tell you what to do.

How has the Swine flu outbreak affected you? Are you staying in more, or avoiding busier places? How about your tips to help avoid infection? Be well.

Wednesday, May 27, 2009

Smoking Is Even More Dangerous To Individuals With HIV Than Those Without

If you have HIV and are a smoker, you now have another reason to quit. In recent research done by Syed Kadri at Ohio State University Medical Centre, patients with HIV were found to be twice as likely to experience a decrease in lung function.

The immediate effects of quitting smoking are:
*Within 8 hours, carbon monoxide levels drop in your body and oxygen levels in your blood increases.
*After 2 days, your sense of smell and taste begin to improve.
*Within 2 weeks to 3 months, your lungs work better making it easier to breathe.
*After 1 to 9 months, coughing, sinus congestion, tiredness and shortness of breath improve.

An excellent resource for those who would like to quit, as well as for those who don’t, is the Canadian Cancer Society

How do you feel about being positive and continuing to smoke? Is more information or support needed to assist you break the habit? Be well!

Wednesday, May 6, 2009

Interpretating Your Lab Results, Viral Load

Viral load is the term used to describe the amount of virus in your blood ( # of HIV RNA copies per millilitre). The more HIV viruses that are in your blood, the faster your CD4’s will be depleted and your risk of disease and illness will increase.

When first infected with HIV (sero-converting), your viral load may be around 100,000 or more. This will soon drop to around 10-30 thousand until you start HAART. If your HAART regime is working, your viral load should fall to “undetectable” within approximately 3-6 months. This means that you have less than 40 HIV RNA copies per ml of blood. One of the goals of HAART is to keep that viral load at “undetectable”. You can expect to have lab tests anywhere from every 1-6 months once your viral load has stabilized.

We’d love to hear your questions about your viral load, or any other lab results that you may receive. Until next week, be well!

Wednesday, April 29, 2009

Interpretating Your Lab Results, CD4 Percentage

This is the second in a four-part series on understanding you lab results.

CD4 percentage answers the question of what percentage of all blood cells are CD4’s? A normal CD4 percentage is approximately 40%, a CD4 percentage of 20% or less is an indicator that HAART should be initiated. Some doctors believe that CD4 percentage should be used in place of CD4 as it is potentially more active, although not as perceptive to smaller changes . In Canada, our doctors receive the CD4 percentage on the same lab form as the CD4 so we do have access to both.


Do you keep track of your lab results? If so, how do you do it? Next week we’ll discuss viral load. Until then, Be well!

Wednesday, April 22, 2009

Interpretating Your Lab Results, CD4

This is the first in a four-part series on understanding you lab results.

“CD4 cells” (“T-helper cells”), are white blood cells which initiate the immune systems response to bacterial, fungal and viral infections. The CD4 count is the number of CD4 cells in a cubic milliliter of blood. (CD4 cells/mm3). A normal CD4 count is anywhere from 500-1,600. After being infected with HIV, our CD4 count will generally drop by approximately 100 cells annually. When your CD4 count is lower than 350, your immune system is weaker and you may get opportunistic infections, current treatment guidelines now suggest starting HAART by this time.

We'd be happy to answer any questions you may have about your lab results. Please drop us a note. Next week we’ll talk about CD4 percentage. Be well!

Wednesday, April 15, 2009

Coping With HIV

A recent study done in the UK found that the top four needs of HIV positive individuals were all related to mental health. Anxiety/depression, self-esteem, sleep and sex, pose the largest problems to the most people. The study also found that the largest and most often used resources for these problems were friends and family.

Living with HIV is for most people one of the hardest things that they will do in their life. Thanks to science and research, we can now expect to live pretty much as long as those without HIV, but it does take some work. Doctors and clinicians can help with mental health problems, but most of us can get significant help and support from our friends and family.

How do you cope with mental health issues due to being HIV positive? Your friends are always a great place to start.