Posted onMarch 24, 2016byr|Comments Off on Today is World Tuberculosis Day. What could this mean for you?
World Tuberculosis Day is marked every year on 24 March, highlighting one of the world’s top health challenges. With nine million new cases and 1.5 million deaths each year, tuberculosis is an ongoing epidemic.
For World TB Day 2015, the United Nations, the Stop TB Partnership and the World Health Organization are calling on all governments and health organisations to mobilise political and social commitment for further progress towards eliminating the disease as a public health burden. The theme this year is “Reach the 3 Million: Reach, Treat, Cure Everyone” – aimed at securing care for the three million who fail to be treated every year.
The date commemorates the day in 1882 when Dr Robert Koch, the German physician and pioneering microbiologist, announced to the University of Berlin’s Institute of Hygiene that he had discovered the cause of tuberculosis. His discovery marked a turning point in the story of the virulent human infectious disease.
Yet over a century on, the disease continues to be a public health problem, with the highest rates in Sub-Saharan Africa. A report by the European Centre for Disease Prevention and Control and WHO found that 1,000 people a day throughout Europe develop the disease and although the continent has experienced an annual 6% decline, Europe will not be TB-free until the next century.
There has been a sustained decline in cases over the last decade but rates of multi-drug resistant tuberculosis, MDR-TB, remain at very high levels.
WHO regional director for Europe, Zsuzsanna Jakab, said only 50% of an estimated 75,000 multi-drug resistant TB patients were found in 2013 and just half were successfully cured.
“Multi-drug resistant TB is still ravaging the European region, making it the most affected area of the entire world,” he said.
TB & HIV Co-infection
When people have a damaged immune system, such as people with HIV who are not receiving antiretroviral treatment, the natural history of TB is altered. Instead of there being a long latency phase between infection and development of disease, people with HIV can become ill with active TB disease within weeks to months, rather than the normal years to decades.
The risk of progressing from latent to active TB is estimated to be between 12 and 20 times greater in people living with HIV than among those without HIV infection. This also means that they may become infectious and pass TB on to someone else, more quickly than would otherwise happen. Overall it is considered that the lifetime risk for HIV negative people of progressing from latent to active TB is about 5-10%, whereas for HIV positive people this same figure is the annual risk.
Many people living with HIV are now taking antiretroviral treatment for their HIV infection. This helps their immune system, but the risk of developing active TB is still higher than in people without HIV infection. Also, there are reports from some African countries that people are starting to become infected with drug resistant HIV. This makes it much more difficult to provide them with effective antiretroviral therapy, and this in turn could result in millions more, of the estimated 40 million people thought to be living with HIV worldwide, developing active TB in the next few years.
Posted onMarch 24, 2015byr|Comments Off on Today is World Tuberculosis Day. What could this mean for you?
World Tuberculosis Day is marked every year on 24 March, highlighting one of the world’s top health challenges. With nine million new cases and 1.5 million deaths each year, tuberculosis is an ongoing epidemic.
For World TB Day 2015, the United Nations, the Stop TB Partnership and the World Health Organization are calling on all governments and health organisations to mobilise political and social commitment for further progress towards eliminating the disease as a public health burden. The theme this year is “Reach the 3 Million: Reach, Treat, Cure Everyone” – aimed at securing care for the three million who fail to be treated every year.
The date commemorates the day in 1882 when Dr Robert Koch, the German physician and pioneering microbiologist, announced to the University of Berlin’s Institute of Hygiene that he had discovered the cause of tuberculosis. His discovery marked a turning point in the story of the virulent human infectious disease.
Yet over a century on, the disease continues to be a public health problem, with the highest rates in Sub-Saharan Africa. A report by the European Centre for Disease Prevention and Control and WHO found that 1,000 people a day throughout Europe develop the disease and although the continent has experienced an annual 6% decline, Europe will not be TB-free until the next century.
There has been a sustained decline in cases over the last decade but rates of multi-drug resistant tuberculosis, MDR-TB, remain at very high levels.
WHO regional director for Europe, Zsuzsanna Jakab, said only 50% of an estimated 75,000 multi-drug resistant TB patients were found in 2013 and just half were successfully cured.
“Multi-drug resistant TB is still ravaging the European region, making it the most affected area of the entire world,” he said.
TB & HIV Co-infection
When people have a damaged immune system, such as people with HIV who are not receiving antiretroviral treatment, the natural history of TB is altered. Instead of there being a long latency phase between infection and development of disease, people with HIV can become ill with active TB disease within weeks to months, rather than the normal years to decades.
The risk of progressing from latent to active TB is estimated to be between 12 and 20 times greater in people living with HIV than among those without HIV infection. This also means that they may become infectious and pass TB on to someone else, more quickly than would otherwise happen. Overall it is considered that the lifetime risk for HIV negative people of progressing from latent to active TB is about 5-10%, whereas for HIV positive people this same figure is the annual risk.
Many people living with HIV are now taking antiretroviral treatment for their HIV infection. This helps their immune system, but the risk of developing active TB is still higher than in people without HIV infection. Also, there are reports from some African countries that people are starting to become infected with drug resistant HIV. This makes it much more difficult to provide them with effective antiretroviral therapy, and this in turn could result in millions more, of the estimated 40 million people thought to be living with HIV worldwide, developing active TB in the next few years.
Posted onJuly 15, 2014byr|Comments Off on 10 things you need to know about the pill to prevent HIV
It’s been called, simultaneously, a medicine to “end the HIV epidemic” and a “party drug:” Pre-exposure prophylaxis, or PrEP for short, refers to a daily antiviral treatment that prevents HIV.
That’s right: People who don’t have the virus can take a pill a day to save themselves from getting infected.
Haven’t heard about PrEP? You’re probably not alone. The drug-maker, Gilead, doesn’t advertise Truvada (its brand name) for prevention, and the Centres for Disease Control and Prevention only endorsed it this past May—two years after it hit the market.
Going forward, however, you’ll be hearing a lot more. On Friday, the World Health Organization backed the antiviral, recommending all HIV-negative men who have sex with men consider taking it as part of a strategy to reduce the global incidence of the disease. But there’s a lot more to the story. Here’s what you need to know:
1) Public health officials aren’t recommending this pill for “all gay men,” despite what the headlines say
The pill is “for people who do not have HIV but who are at substantial risk of getting it,” according to CDC guidance. “At substantial risk” means you regularly have unprotected sex with partners of unknown HIV status. This can include men who have sex with men, heterosexual men and women, injection drug users, sex workers, and people in couples with an HIV-positive partner. In other words, not simply “all gay men.”
The latest headlines about Truvada were so misleading that the WHO had to issue a clarification noting that they support PrEP “as an additional choice”—again, not for all men who have sex with men.
“We know from surveillance that condom use is not as high as is necessary to control the epidemic”
2) Truvada is not a condom replacement
Public-health officials are not endorsing Truvada as an alternative to other forms of protection. “We are suggesting that for people who are already not using condoms, we have another option to help protect them from HIV infection,” says the CDC’s Dawn Smith, biomedical interventions implementation officer. “It’s part of being practical and realistic.” So the hope is that those who get prescriptions are folks who just aren’t using anything to protect themselves. “We know from our surveillance systems that condom use is not as high as is necessary to control the epidemic,” Smith added.
3) We don’t yet know exactly how the drug will be used in real life
Still, this public-health message hasn’t stopped some activists and AIDS campaigners from worrying aloud that the pill will undermine traditional advocacy messages about condoms—especially at a time when HIV infections are on the rise among gay men. And the truth is, we don’t yet know what kind of impact PrEP will have on people’s behaviour.
To find out, there are now “demonstration trials” being run around the world. These will look at how Truvada works outside of clinical trials, the impact of non-daily use of the drug, and whether the antiviral encourages more risky sexual behaviour or leads to an increase in other sexually-transmitted infections.
4) We do know Truvada only works effectively when taken every day
A three-year clinical trial of PrEP in HIV-negative men who have sex with men found that users got much more protection when they took the drug every day. Participants who took the drug less than half the time had a 50 percent reduction in HIV acquisition; daily users cut their risk by more than 90 percent. These results have been supported by other studies in a range of populations—from injection-drug users to heterosexual men and women. The trouble is, most people don’t take their medications as their doctors prescribe.
Drug-resistant strains of HIV have emerged when people with acute, undetected infection were given Truvada
5) Truvada can cause drug-resistant HIV infection
Drug-resistant strains of HIV have emerged when people with acute, undetected infection were given PrEP. This means they were positive when they started the medicine, but levels of the virus in their blood were hardly detectable because their infections were so new. They hadn’t made enough antibodies to show up in a test and so they were prescribed the drug anyway.
There’s some question about how serious this risk is for individuals and public health. For now, doctors are asked to confirm the HIV status of patients and to do follow-up and re-testing throughout treatment.
When asked how much of a concern drug resistance is, Smith of the CDC said, “We don’t know yet. That’s one of the things we’ll learn as the first few demonstration projects begin telling us.”
6) Besides that, it’s pretty safe
Though Truvada for the prevention of HIV was only licensed by the Food and Drug Administration in 2012, it was first authorizedin 2004 to treat HIV positive patients. That’s right: the same drug used for these two purposes. Since it has been on the market as a treatment for over a decade—with very minimal side effects and harms—doctors are pretty confident in its safety profile for preventative use. There seem to be few side-effects with Truvada for prevention, the most common one being nausea.
People have been slinging the term ‘Truvada whore’ around, and the head of the aids healthcare foundation called the pill a ‘party drug’
7) “Truvada whores” are a thing
Because of the questions about whether PrEP will cause people to have risky sex and ditch condoms, there’s some related stigma in the gay community. People have even been slinging the term “Truvada whore” around, and the head of the AIDS Healthcare Foundation called Truvada a “party drug.” In response, one PrEP activist created a #TruvadaWhore t-shirt campaign to reclaim the word.
Many have pointed out that this divide parallels the early days of the birth control pill and suggestions that the medication would encourage promiscuity.
8) Uptake has been slow—but that’s not the full story
According to data from the drug maker Gilead, by March 2013 there were approximately 1,774 people in the US taking the drug. But it’s important to put this number in context. First of all, these findings were not published and peer-reviewed; they were presented at a scientific conference last year. When studied, we’ll have a better picture of the PrEP landscape and it may look quite different. Secondly, Truvada has only been on the US market for prevention since 2012, a year after these numbers were gathered. It often takes decades for innovations to penetrate a market, especially in the conservative field of medicine.
9) The drug is expensive
Without insurance, Truvada can cost up to $14,000 a year, according to the CDC. But for most people, it is covered in their insurance programs and there’s only a co-pay. There are also medication assistance programs across the US for the uninsured that will cover the entire cost of the medication.
10) HIV remains a socio-economic crisis around the world
Globally, men who have sex with men, prisoners, injection-drug users, and sex workers are still the groups most affected by HIV.
An intensive campaign to combat HIV/AIDS with costly antiretroviral drugs in rural South Africa has increased life expectancy by more than 11 years and significantly reduced the risk of infection for healthy individuals, according to new research.
The two studies, published Thursday in the journal Science, come as wealthy Western nations are debating how best to stretch limited AIDS funding at a time of economic stress.
With an annual price tag of $500 to $900 per patient, antiretroviral therapy programs have stirred frequent debate. Critics argue that adherence to the drug regimen is low and social stigma prevents some from seeking care until they are very ill and have infected others. Cheaper remedies, such as condom distribution, male circumcision and behavior modification, deserve more attention and funding, they say.
The new economic analysis of a $10.8-million campaign in KwaZulu-Natal province concluded that the drug scale-up there had been highly cost-effective.
The program was administered by nurses in rural health clinics in an impoverished region of about 100,000 people. Treatment consisted primarily of daily doses of antiretroviral therapy, or ART, drugs, which patients take every day for their entire lives. Patients picked up their medication at a rural clinic once a month.
In 2003, the year before the drugs were available, 29% of all residents were infected with HIV and half of all deaths there were caused by AIDS. Life expectancy in the region was just over 49 years.
By 2011, life expectancy had grown to 60 1/2 years — “the most rapid life expectancy gains observed in the history of public health,” said study senior author Till Barnighausen, a global health professor at the Harvard School of Public Health.
Based on that increase in longevity, researchers determined just how many years of life were effectively “gained” among residents as a result of ART intervention. They used that figure and the total expense of the program to calculate a cost-effectiveness ratio of $1,593 per life-year saved.
The World Health Organization considers medical intervention to be “highly cost-effective” if the cost per year of life saved is less than a nation’s per capita gross domestic product. The program’s ratio was well below South Africa’s 2011 per capita GDP of about $11,000.
“It’s really a slam dunk of an intervention,” said study leader Jacob Bor, a graduate student at Harvard. “These investments are worthwhile.”
The research team noted that the study period coincided with the arrival of electric power and clean water for area residents. But those alone could not explain the dramatic increase in longevity, they said.
“While mortality due to HIV declined precipitously, mortality due to other causes flat-lined,” Bor said. “These changes were almost certainly due to ART scale-up.”
In a second study from the same region, researchers followed nearly 17,000 healthy people from 2004 to 2011 to determine HIV infection rates in areas with active ART intervention programs.
Healthy individuals in those areas were 38% less likely to contract HIV than people in areas where ART drugs were not widely available, researchers found. People in extremely rural areas also fared better than those in more closely populated areas clustered around national roads.
Overall HIV prevalence increased 6% during the seven years of the study, probably because the antiretroviral drugs allowed people with the virus to live longer, according to the report.
It’s not clear how the results of the new study would translate to areas where stable, cohabiting couples were not the norm, said lead author Frank Tanser, an epidemiologist at the University of KwaZulu-Natal.
AIDS researchers who weren’t involved in the studies said they provide strong support for maintaining programs like the President’s Emergency Plan for AIDS Relief, begun by President George W. Bush in 2003.
“These papers present truly remarkable data,” said Dr. Douglas Richman, director of the Center for AIDS Research at UC San Diego.
As we prepare to enter our 25th year, we are reflecting on the global HIV events from the last three decades. HIV has swept across the globe touching communities on every continent. Here’s an introduction to some of the key moments in the early global history of HIV. Catch up on the story using the ‘Recent Posts’ link to the right.
UNAIDS and the World Health Organization (WHO) estimated in 1996 that more than 4.6 million people had died from AIDS since the beginning of the epidemic and that over 20.1 million were then living with the virus that leads to AIDS. The majority of those infected (over 15 million) lived in sub-Saharan Africa, followed by more than 31.8 million in Asia, 1 million in Latin America and the Caribbean and about 1.5 million in North America and Western and Central Europe.
On 1 January 1996, The UN aids agency, UNAids, is established. UNAids – the Joint United Nations Programme on HIV/AIDS opened for business. This was 15 years after the first published report of AIDS cases, 15 years during which most of the world’s leaders, in all sectors of society, had displayed a staggering indifference to the growing challenge of this new epidemic.
Tommy Morrison in February, 2007
In February, the heavyweight boxer Tommy Morrison was identified as HIV positive after being tested prior to a fight. A few days before a scheduled fight against Arthur Weathers, Morrison tested positive on a mandatory HIV test performed by the Nevada Athletic Commission. Morrison’s personal physician administered a confirmatory test, which was also positive. Nevada cancelled the fight and placed Morrison on indefinite suspension.
At a news conference, a “reflective” Morrison said that he had contracted HIV because of a “very permissive, fast, reckless lifestyle’ that involved unprotected sex with multiple partners.” Morrison also said that he once thought HIV was a danger only to drug addicts and homosexuals, but that his infection was evidence that HIV “does not discriminate.”Morrison stated that he would never fight again but later in 1996, he announced that he wished to make a comeback with one more bout, the proceeds of which would benefit his newly created KnockOut Aids Foundation.
To treat his HIV infection, Morrison told the New York Daily News in 2001, he took antiretroviral medication, which reduced his viral load to low levels and according to his promoter, saved his life.
Beginning in 2006, Morrison launched a comeback bid, alleging that his positive HIV tests had been false positives or that he was a victim of a plot by a rival boxer. The Nevada boxing commission’s medical advisory board reviewed Morrison’s status and concluded that the HIV positive results were “ironclad and unequivocal.” The commission’s Keith Kizer stated, “I hope he’s HIV negative, I really do, but it doesn’t seem likely…We’ll wait and see what happens. He said he’s been tested several times in recent years, but (we’ll ask) what happened from 1996 and 2002, the years he won’t talk about.” Morrison said he tried to get a copy of the original test results. “We’ve asked, but they can’t come up with it,” he said. “I don’t think it ever existed.” USA Today reported that “Goodman said that’s nonsense: ‘All Mr. Morrison has to do is contact the laboratory, and they would immediately release the results to him.’
It’s very interesting reading, for more on Tommy Morrison, follow these links:
Meanwhile in China it was estimated that the number of AIDS cases could be as high as 100,000. Two thirds of the reported AIDS cases had occurred in the southern province of Yunnan, where the use of heroin and the sharing of needles had helped the spread of HIV.
In the USA there had been a cumulative total of 81,500 AIDS cases in New York.
New outbreaks of HIV infection were erupting in Eastern Europe, the former Soviet Union, India, Vietnam, Cambodia, China and elsewhere.
The International Aids Vaccine Initiative set up to jumpstart the search for an effective vaccine.
The first major breakthrough in the treatment of HIV comes in 1996, with the introduction of protease inhibitors as part of antiretroviral combination therapies.
Protease Inhibitors stop HIV replication by preventing the enzyme protease from cutting the virus into the shorter pieces that it needs to make copies of itself. Incomplete, defective copies are formed which can’t infect cells.
This new class of medicine means that viral loads drop, t-cells rise, and death rates plummet, even as it becomes clear that the new medications cannot “eradicate” HIV from the body and thus fall short of being a cure. Alongside these tremendous advances, new HIV infections remain undiminished, and the drugs also prove difficult to take, cause serious side effects, and don’t work for everyone.
Robert Gallo, an American biomedical researcher, best known for his role in the discovery of HIV published his discovery that chemokines, a class of naturally occurring compounds, can block HIV and halt the progression of AIDS. This was heralded by Sciencemagazine as one of the top scientific breakthroughs within the same year of his publication. The role chemokines play in controlling the progression of HIV infection has influenced thinking on how AIDS works against the human immune system and led to a class of drugs used to treat HIV, the chemokine antagonists or entry inhibitors.
Gallo’s team at the Institute of Human Virology maintain an ongoing program of scientific research and clinical care and treatment for people living with HIV/AIDS, treating more than 4,000 patients in Baltimore and 200,000 patients at institute-supported clinics in Africa and the Caribbean. In July 2007, Gallo and his team were awarded a $15 million grant from the Bill and Melinda Gates Foundation for research into a preventive vaccine for HIV/AIDS.
Just 12 months earlier, AIDS was considered a death sentence, and those seeking to treat it seldom uttered the words “AIDS” and “hope” in the same sentence. However, in 1996 those terms have become inextricably linked in the minds and hearts of researchers and patients alike and while the new optimism must be tempered with numerous caveats, 1996 had ushered in a series of stunning breakthroughs, both in AIDS treatment and in basic research on HIV.
Protease inhibitors can now dramatically reduce HIV levels in the blood when taken with other antiviral compounds. At the same time, natural weapons in the immune system’s defences, polypeptide molecules called chemokine’s, have been unveiled as potent foes of HIV. This work offered new insight into the pathogenesis of HIV and may one day blossom into new treatments or even vaccines.
These major breakthroughs resulted in a steep decline in the number of AIDS cases and deaths reported each year which gave hope to the many millions of people with HIV. Less and less people with HIV were dying however, the number of infections continues to rise, and peaks at a new high from 2000, due in part to living healthy with HIV but also due to decreased education and awareness.
At the 11th International Aids Conference in Vancouver, excitement over the development of combination drug therapies is tempered by their extreme cost – estimated at $20,000 a year per patient.
Brazil introduces free combination therapy for HIV-positive citizens
At the end of the year UNAIDS estimated that during 1996 some three million people, mostly under the age of 25, had become newly infected with HIV, bringing to nearly 23 million the total number of infected people. In addition an estimated 6.4 million people – 5 million adults and 1.4 million children – had already died.
As we prepare to enter our 25th year, we are reflecting on the global HIVevents from the last three decades. HIV has swept across the globe touching communities on every continent. Here’s an introduction to some of the key moments in the early global history of HIV. Catch up on the story using the ‘Recent Posts’ link to the right.
By 1st January 1995, a cumulative total of a million cases of AIDS had been reported to the World Health Organisation Global Programme on AIDS. Eighteen million adults and 1.5 million children were estimated to have been infected with HIV since the beginning of the epidemic.
AIDS had become the leading cause of death amongst all Americans aged 25 to 44.
Two research reports provided important new information about how HIV replicates in the body and how it affects the immune system.
The South African Ministry of Health announced that some 850,000 people – 2.1 percent of the 40 million population – were believed to be HIV positive. Among pregnant women the figure had reached 8 percent and was rising.
By the autumn of 1995, 7-8 million women of childbearing age were believed to have been infected with HIV.
By December 15th, the World Health Organisation had received reports of 1,291,810 cumulative cases of AIDS in adults and children from 193 countries or areas. The WHO estimated that the actual number of cases that had occurred was around 6 million. Eight countries in Africa had reported more than 20,000 cases.
Other organisations estimated that by the end of 1995, 9.2 million people worldwide had died from AIDS.
Worldwide during 1995, it was estimated that 4.7 million new HIV infections occurred. Of these, 2.5 million occurred in Southeast Asia and 1.9 million in sub-Saharan Africa. Approximately 500,000 children were born with HIV.
The WHO estimated that by the end of the century, 30 to 40 million people would have been affected by HIV.
British DJ and entertainer Kenny Everett dies from AIDS on 4 April 1995.
Posted onOctober 18, 2011byr|Comments Off on Testing people with conditions suggesting HIV could pick up more recent infections, Europe-wide study finds
A pilot study in 14 European countries, in which groups of patients presenting with one of eight conditions strongly associated with HIV were routinely tested for HIV in various medical settings, found an HIV prevalence rate of 1.8%. This is far in excess of national rates and of the 0.1% prevalence rate suggested by the US Centres for Disease Control for routine HIV testing of the population, and suggests targeting people with these so-called indicator conditions (ICs) for HIV testing could be an efficient way of detecting infection.
The study found relatively high CD4 counts and a high prevalence in patients presenting with mononucleosis-like illness. These symptoms are usually caused by Epstein-Barr virus but may also be due to HIV seroconversion. This suggests that testing for indicator conditions might be a good way of detecting more people in early HIV infection.
The HIDES I study arose from the HIV in Europe conference in 2007, which debated how to improve HIV testing rates and reduce the amount of undiagnosed HIV in the region.
One method suggested was to draw up a list of indicator conditions (ICs) associated with HIV probability of HIV infection and recommend that people presenting of these should be routinely tested.
HIDES I drew up a shortlist of eight ICs and sent out a call to healthcare centres in Europe to participate in the study to test the feasibility and acceptability of routine IC-driven HIV testing.. This would involve them routinely test all patients consecutively presenting with a specific IC.
The eight conditions chosen were:
Acute STIs
Hepatitis B or C
Malignant lymphoma of any type
Anal or cervical intraepithelial neoplasia (HPV disease) grade 2 or above
Unexplained low platelets (thrombocytopenia) or neutrophils (neutropenia) for more than four weeks
Herpes zoster (shingles) in people under 65
Seborrhoeic dermatitis or exanthema (sudden rash)
Mononucleosis-like illness.
Results: demographics
Seventeen centres in 14 European countries spread over the whole continent from UK to Ukraine participated in HIDES I. They conducted 39 separate surveys on HIV testing in patients presenting with ICs between September 2009 and February 2011. There were one to six surveys conducted in each centre and between three to six surveys conducted for each indicator condition.
Altogether, 3588 patients were tested for HIV. They had an average age of 36, which varied according to condition from 24 for mononucleosis to 53 for lymphoma. Fifty-five per cent were men and a quite high proportion (36%) had had a previous HIV test.
Sex, age, sexuality and previous testing rates varied by European region. Patients were youngest (average 33) in northern Europe (UK, Netherlands, Denmark, Sweden) and oldest (43) in southern Europe (Italy and Spain). Roughly two-thirds were male in all European regions apart from northern Europe, where 44% were male.
Only two per cent of patients in eastern Europe (Belarus, Ukraine, Bosnia, Croatia, Poland) said they were gay compared with approximately 40% in south and west central Europe (Germany, Austria, Belgium) and 45% in northern Europe; and only 13% in eastern Europe had had a previous HIV test compared with 36% in southern, 45% in west central, and 60% in northern Europe.
Results: HIV diagnoses
There were 66 new HIV diagnoses (1.8% of patients). Eighty-three per cent of those diagnosed were male, 58% of them were gay, 42% heterosexual and 9% had injected drugs. The prevalence of newly-diagnosed HIV varied widely from 0.6% in northern Europe to 6.5% in southern.
It also varied widely per IC. Not unexpectedly the highest HIV diagnosis rate was in surveys involving STIs (4%) but it was not much lower in mononucleosis-like illness (3.8%), neutro/thrombocytopenia (3.2%), shingles (2.9%) and dermatitis/rash (2.1%).
In contrast HIV prevalence was only 0.4% in cervical/anal dysplasia and hepatitis B/C and 0.3% in lymphoma, possibly because the individuals with these diseases who have HIV are more likely to have already been diagnosed. These rates are still above the 0.1% rate considered cost-effective for routine testing, though.
Over the whole group, more than half of those diagnosed with HIV(52%) had been tested for it before, with a median time from their previous HIV test of 19 months. Their average CD4 count was 400. This may indicate that offering an HIV test as standard when ICs are diagnosed may detect more cases of early HIV infection, though presenter Ann Sullivan of London’s Chelsea and Westminster Hospital did not split this analysis into European regions. It is possible that the relatively high amount of recent infections may be driven by tests given to people presenting with STIs who might have tested anyway.
HIDES 1 found that 20% of patients had presented to healthcare with one of the ICs in the preceding five years and 4.6% had presented more than once.
Next steps
The HIDES project now intends to conduct a larger HIDES 2 study involving 12 indicator conditions, in order to establish better HIV prevalence figures for each. It also intends to conduct a separate audit of whether patients in Europe who present with ICs are offered HIV tests. Finally they intend to develop, in collaboration with the European Centre for Disease Control and the World Health Organization, a set of guidelines for HIV testing targeted at indicator conditions.
HIDES investigator Jens Lundgren commented from the audience that although HIDES 1 was a pilot study, its results were important because many physicians had been sceptical that using ICs to guide HIV testing would find higher than average rates of HIV or be cost-effective. These results showed that it was an efficient way to find undiagnosed HIV.
Posted onSeptember 28, 2011byr|Comments Off on HIV Treatment at 500 CD4 Level Would Put Half of Patients in Need of ART Within a Year of Seroconversion
Raising the CD4 cell threshold for the initiation of antiretroviral therapy to 500 cells/mm3 would mean that almost 50% of patients would need to start HIV treatment within a year of their infection with HIV, investigators from an international study of seroconverters report in the October 15th edition of Clinical Infectious Diseases.
A threshold of 350 cells/mm3 would result in approximately a third of patients starting therapy within a year of infection with the virus.
Large numbers of patients with HIV are diagnosed late and the investigators comment: “Our findings provide strong support for public health campaigns to encourage early HIV infection diagnosis and testing.”
US HIV treatment guidelines now recommend that patients should start antiretroviral therapy when their CD4 cell count falls below 500 cells/mm3. European guidelines endorse treatment at a CD4 threshold of 350 cells/mm3, as do World Health Organization (WHO) guidelines for middle- and low-income countries.
The earlier initiation of HIV therapy appears to have several advantages. For instance, the results of observational studies suggest that it reduces the risk of both HIV-related and non-HIV-related illnesses. Moreover, prompt therapy may also have public health benefits, significantly reducing the risk of onward HIV transmission.
But raising the CD4 cell threshold for the initiation of therapy will have cost implications for health systems, many of which are already struggling. An accurate understanding of the length of time between infection with HIV and a fall in CD4 cell count low enough to merit therapy is needed to assist planning.
Investigators from the CASCADE (Using Concerted Action on AIDS and Death In Europe) study analysed the medical records of 18,495 individuals with a known date of HIV seroconversion to predict the amount of time between infection with the virus and a fall in CD4 cell count to below 500, 350 and 200 cells/mm3. They also calculated the proportion of patients who would reach these CD4 cell count thresholds one, two and five years after infection with HIV.
Most of the patients (78%) were men and were infected with HIV through sex with another man (55%). Median age at the time of serconversion was 30 years.
The median length of follow-up was 3.74 years.
According to the investigators’ calculations, median CD4 cell counts one, two and five years after infection with HIV were 510 cells/mm3, 460 cells/mm3 and 315 cells/mm3, respectively.
If guidelines recommended HIV therapy at a CD4 cell count of 500 cells/mm3, then 48% of individuals would need to start treatment within a year of seroconversion. This compared to 26% of patients if the threshold was 350 cells/mm3 and 9% of individuals if the level was 200 cells/mm3.
The estimated median times between seroconversion and a drop in CD4 cell count to below 500, 350 and 200 cells/mm3 were 1.19, 4.19 and 7.93 years respectively.
However, CD4 cell loss differed according to individual patient characteristics. Older age was associated with a lower CD4 cell count at the time of seroconversion and faster loss of CD4 cells during follow-up (p < 0.001). In addition, individuals infected with HIV via injecting drug use or heterosexual contact had a steeper CD4 cell count decrease than gay men (p < 0.001).
The investigators calculated the time between seroconversion and a fall in CD4 cell count to the study thresholds for three groups of patients.
For heterosexual women aged 25 to 30, the median times between seroconversion and a fall in CD4 cell count below 500, 350 and 200 cells/mm3 were 10.71, 5.66 and 1.63 years respectively.
The times for gay men aged 30 to 35 years were 0.95, 3.94 and 7.67 years, and 0.04, 4.08 and 9.15 years for heterosexual men in the same age group.
“These data signify a substantial increase in the number of individuals who require treatment within the first 5 years after becoming infected following the recent changes in [US and WHO] guidelines,” write the authors. “These estimates…will be essential to health care planners estimating the additional costs of increasing the CD4 cell count threshold for cART (combination antiretroviral therapy) initiation.”
The investigations add: “Our data urgently call for a campaign to encourage early HIV testing to ensure that infected individuals receive a diagnosis of HIV infection and access care well before they reach the CD4 cell count threshold at which treatment is indicated.”
The following video features an excellent 3D animation which explains the HIV replication process very clearly. Available from Dr Rufus Rajadurai YouTube page
LASS 