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Peran Dokter Indonesia dalam Penanggulangan Epidemi HIV-AIDS di Indonesia
Saat ini sudah waktunya upaya peningkatan program penanggulangan HIV-AIDS yang komprehensif sehingga dapat berpengaruh secara nyata dan optimal dalam penanggulangan HIV-AIDS di Indonesia, termasuk keterlibatan peran organisasi profesi kesehatan, seperti IDI (Ikatan Dokter Indonesia) dalam upaya penanggulangan HIV/AIDS secara nasional.
Selain adanya percepatan epidemi HIV, Indonesia juga menghadapi masalah epidemi pengunaan napza (narkoba dan zat adiktif), yang masih menjadi kontribusi utama penularan HIV, selain itu adanya peningkatan transmisi dari blood-borne virus, seperti penularan virus hepatitis B dan C, serta HIV.
Perluasan transmisi semakin kompleks karena penularan seksual yang tidak dapat dihentikan, karena rendahnya pemakaian kondom pada seks berisiko.
Dampak epidemi HIV-AIDS tidak mudah ditanggulangi, adanya masalah koinfeksi pada orang-orang yang terkena HIV. Problema koinfeksi HIV dengan HCV, HBV, TB, serta penyakit infeksi lainnya mendorong penanganan yang lebih komprehrensif. Koinfeksi tidak saja dapat memperburuk status kesehatan orang dengan HIV, juga HIV itu sendiri mempercepat situasi dampak buruk infeksi lainnya.
Pada umumnya tenaga profesi kesehatan di Indonesia belum siap menghadapi epidemi HIV dengan problema koinfeksinya, sehingga diperlukan advokasi untuk pengembangan kurikulum kedokteran dan pendidikan dokter berkelanjutan (Continuing Professional Development) yang dapat meningkat kompetensi dokter Indonesia dalam mengenali dan menangani koinfeksi HIV dengan pathogen lainnya.
Selain itu penularan HIV semakin meluas ke pasangan seksnya (isteri) dan anaknya. Pada umumnya ketahanan hidup anak dengan HIV juga masih buruk.
Semua permasalahan ini mendorong Ikatan Dokter Indonesia untuk meningkatkan perannya dalam penanggulangan HIV di Indonesia. Peran yang perlu dijalani sebagai organisasi profesi adalah selain mendorong para anggotanya – para dokter yang bekerja di wilayah Indonesia – untuk tidak saja lebih peduli, tetapi juga terlibat aktif dalam upaya penanggulangan yang bersifat komprehensif dan kontinyu, yaitu dari upaya pencegahan, diagnosis, pengobatan serta dukungan psiko-sosial. Diharapkan tidak perlu terjadi lagi perilaku yang diskriminatif dan stigmatisasi oleh profesional kesehatan dalam hal yang terkait dengan HIV-AIDS.
PB IDI dalam melaksanakan kegiatan akan bekerjasama dengan berbagai pihak antara lain organisasi profesi dokter yang di bawah payung IDI, serta organisasi profesi kesehatan lainnya seperti Ikatan Bidan, Persatuan Dokter Gigi dan Ikatan Apoteker. Selain PB IDI bermitra erat dengan semua unsur di lingkungan Departemen Kesehatan RI. Dalam menggalnag kerjasama dengan organisasi internasional bekerja sama dengan WHO dan ASHM.
PB IDI Anjurkan Sirkumsisi & Penggunaan Kondom: untuk Cegah Penularan HIV
Sirkumsisi dan
Aktifkan Lagi Kampanye Penggunaan Kondom:
Elemen Penting untuk Cegah Penularan HIV-AIDS
Pokja HIV-AIDS PB IDI mendorong agar para dokter Indonesia menganjurkan penggunaan kondom pada siapa saja yang berisiko terkena IMS, termasuk HIV
Pendahuluan
Seperti telah kita ketahui bersama bahwa dalam beberapa tahun terakhir terjadi percepatan laju penularan HIV (virus penyebab AIDS) dan infeksi menular seksual (disingkat IMS, yaitu seperti sifilis, gonore) di Indonesia.
Sejak satu dekade terakhir penularan HIV (virus penyebab AIDS) melalui penggunaan bersama alat suntik narkoba meningkat cukup tajam. Paling tidak, setengah dari pemakai narkoba suntik telah terkena HIV. Seringkali fenomena ini dikenal gelombang pertama dari epidemi HIV di Indonesia.
Selanjutnya penularan HIV terus berlanjut, karena sebagian besar pengguna narkoba (yang separuhnya telah terinfeksi HIV) juga melakukan seks yang cukup aktif, antara lain membeli atau menjual jasa seks. Dapat diramalkan bahwa dapat dilihat peningkatan kejadian infeksi pada pelaku seks aktif dengan pasangan seks yang banyak dan berganti.
Angka Kejadian IMS pada Penjaja seks tertinggi di Asia
Selain itu, angka kejadian infeksi menular seksual (seperti Gonore dan Klamidia) pada penjaja seks perempuan di beberapa kota di Indonesia tercatat sangat tinggi di Asia. Hasil survai Departemen Kesehatan RI pada tahun 2005 pada penjaja seks perempuan di beberapa kota mencatat sekitar 39% sampai 61% mengidap Klamidia atau Gonore.
Padahal adanya infeksi menular seksual dapat mempermudah proses penularan HIV pada kegiatan seks. Hasil peneilitian mengindikasikan bahwa infeksi menular seksual meningkatkan risiko penularan sampai 2-3 kali.
Yang menambah keprihatinan bersama, adanya resistensi dengan obat antibiotika yang tersedia dan terjangkau serta mengkonsumsi obat antiobiotik yang mudah didapat di mana-mana sehingga menyulitkan upaya pengobatan infeksi menular seksual. Hal ini disebabkan perilaku mengobati sendiri bila ada gejala infeksi menular seksual.
Diperkirakan lebih dari 3 juta lelaki di Indonesia yang rajin membeli seks, dan separuh dari lelaki tersebut mempunyai pasangan tetap, atau isteri. Dapat diperkirakan penularan dapat terus berlanjut ke istri, walaupun para isteri tidak mempunyai perilaku seks dengan banyak pasangan. Fenomena tersebut mendorong terjadi epidemi HIV seperti sekarang dan semakin semakin nyata dibandingkan beberapa tahun yang lalu.
Diperkirakan telah lebih dari 200.000 orang terinfeksi HIV di tahun ini dan diramalkan pada tahun 2020 akan meningkat mendekati angka 2 juta, bila upaya pencegahan tidak dilakukan untuk menekan penularan melalui seks berisiko.
Dalam kondisi seperti ini harus diaktifkan lagi kampanye peningkatan penggunaan kondom sebagai alat kesehatan yang secara ilmiah telah terbukti dapat menangkal penularan infeksi menular seksual termasuk HIV. Tidak ada alat atau teknologi kesehatan yang mempunyai kemampuan pencegahan infeksi seperti kondom. Tidak juga teknologi vaksinasi untuk mencegah beberapa penyakit menular.
Hendaknya upaya promosi kondom jangan diartikan sebagai anjuran untuk melakukan kegiatan seks berisiko. Siapapun yang masih melakukan kegiatan seks berisko dianjurkan sangat untuk menggunakan kondom agar dirinya terhindar dari penularan serta tidak menularkan kepada yang lain. Bila tidak mau menggunakan kondom, sebaiknya menghentikan perilaku seks berisiko.
Sirkumsisi dapat mengurangi risiko penularan
Salah satu temuan yang berangkat pengamatan observasional serta eksperimental di masyarakat, ternyata perilaku sirkumsisi pada lelaki dapat mengurangi peluang terkena HIV. Salah satu penjelasannya adalah sebagian kulit kelamin yang dibuang ketika disrkumsisi, ternyata dapat dimasuki HIV, walaupun tidak terdapat ”pintu masuk” berupa penyakit kelamin. Hasil Survai Departemen Kesehatan 2006 juga diindikasikan bahwa penduduk tanah Papua yang tidak disirkumsisi berisiko lebih tinggi untuk terkena HIV.
Sirkumsisi dapat mengurangi risiko rata-rata sepertiga sampai setengahnya dibandingkan pada yang tidak disirkumsisi. Dianjurkan pada lelaki sebelum memasuki usia seksual aktif untuk dilakukan sirkumsisi, sebagai cara untuk menjaga higiene alat kelamin dan mengurangi risiko terkena HIV.
Ternyata sirkumsisi hanya memberikan perlindungan parsial, karena itu pada lelaki yang juga telah disirkumsisi dianjurkan perlu tetap menggunakan kondom pada yang melakukan kegiatan seks berisiko.
Menurunkan kejadian infeksi menular seksual
Cara terbaik untuk menghindari terkena infeksi menular seksual adalah dengan tidak melakukan seks berisiko, yaitu tidak berganti dan punya banyak pasangan seks, atau tidak punya pasangan seks yang berperilaku berisiko.
Bila tidak maka pemakaian kondom pada setiap kegiatan seks menjadi keharusan, termasuk dengan pasangan tetapnya, agar tidak terkena IMS atau menularkan kepada yang lain termasuk pasangan tetapnya.
Bila ada gejala IMS segera berobat dengan benar, karena dapat diobati dan dapat menurunkan risiko penularan HIV.
PB IDI perlu mempromosikan sirkumsisi pada lelaki sebelum memasuki usia seksual aktif.
Pokja HIV-AIDS PB IDI perlu menyatakan bahwa kondom adalah alat kesehatan yang mampu mencegah penularan infeksi menular seksual bila digunakan pada setiap kegiatan seks berisiko. Selain itu mendorong para dokter dan tenaga kesehatan lainnya untuk menganjurkan pada masyarakat untuk pakai kondom pada setiap seks yang berisiko. Cara yang mudah, murah, dan aman dibandingkan setelah terkena penyakit.
Jakarta, 13 Desember 2007
Ketua Umum,
DR. Dr. Fachmi Idris, M.Kes
NPA. IDI : 32.552
Predictors of mortality among HIV-positive children in resource-limited settings
The first large-scale meta-analysis of prognostic markers among HIV-positive children living in resource-limited settings has provided valuable insight in how to improve care for HIV-infected children. The research, published in the January 2nd issue of AIDS, confirms the predictive value of CD4 percentages and CD4 counts and reasserts the need to provide affordable and feasible lab tests in the developing world. The study also identifies growth measures as useful predictors and stresses the importance of addressing non-HIV related issues such as malnutrition and anaemia in HIV-positive children.
At the end of 2006, nearly 90% of the estimated 2.3 million children living with HIV worldwide were from sub-Saharan Africa. With no anti-HIV therapy, African children born with HIV have a median survival age of two years, compared with eight to ten years for children born in Europe of the US.
Anti-HIV treatment in children faces considerable gaps in knowledge, including when to start therapy in countries where access to treatment is limited. The WHO paediatric treatment guidelines for resource-limited settings are largely based on data from the HIV Paediatric Prognostic Collaborative Study (HPPMCS), a meta-analysis of studies performed in developed world settings. Similar data from resource-limited settings is lacking.
3Cs4kids in resource-limited settings
To begin addressing this gap, the Cross Continents Collaboration for Kids (3Cs4kids) study undertook a large-scale analysis of mortality predictors among children in resource-limited settings. The study team, which included researchers from the MRC Clinical Trials Unit, performed a meta-analysis of ten studies (nine African and one Brazilian) that included individual longitudinal data from 2510 children. Researchers evaluated the value of selected laboratory tests and growth markers in predicting short-term risk of death.
The researchers included the following markers: CD4 percentage (CD4%), CD4 cell count, total lymphocyte count (TLC), haemoglobin, weight-for-age, height-for-age and BMI-for-age. Results were adjusted for use of cotrimoxazole (Septrin), which is estimated to reduce risk of death among HIV-positive children by 43%.
Median age of the children at first measurement was 4.0 years, and median follow up per child was 12.7 months. Median CD4% was 15% and median weight-for-age was a z-score of -1.9 when compared to the UK reference for HIV-negative children.
Overall, there were 357 deaths among 3769 child-years-at-risk. After adjusting for age, cotrimoxazole prophylaxis and study effects, all markers individually predicted 12-month mortality. Statistical analysis revealed that CD4 cell count and CD4% were the strongest predictors, followed by weight-for-age, height-for-age, haemoglobin, BMI-for-age and TLC.
In multivariable analyses, weight-for-age and haemoglobin remained strongly predictive of death, even after controlling for CD4% or CD4 count. Conversely, there was a steady increase in risk with decreasing CD4% or CD4 count at any specific weight-for-age and haemoglobin value. However, both CD4% and CD4 count were less predictive at lower weight-for-age values.
Comparing 3Cs4kids to HPPMCS
While results from the 3Cs4kids study generally supported those from HPPMCS, there were several notable differences. The twelve-month risk of death estimated by CD4%, CD4 cell count and TLC was generally higher with 3Cs4kids than HPPMCS at any given marker value and age. Moreover, the increase in risk with decreasing marker value was more gradual and occurred at higher thresholds in 3Cs4kids.
Current WHO guidelines recommend that the decision to start therapy be guided by clinical stage or monitoring CD4 percentage and count or TLC. However the researchers note, “The steep rise and threshold effect in mortality risk with falling marker values observed in HPPMCS, which influenced the choice of marker thresholds for ART initiation in the WHO guidelines, was less pronounced in 3Cs4kids. Consequently, both CD4% and count were less effective in discriminating between low and high mortality levels for children in resource-limited settings.“
As well, in contrast with the industrialized setting of HPPMCS where TLC was highly prognostic, TLC was a poor predictor of death among children in resource-limited settings. TLC retained only a small independent effect after adjusting for CD4% or CD4 count, and TLC had no additional prognostic value if CD4 count was known.
Importance of nutrition
The 3Cs4kids study also underscored the significance of nutritional support and prevention and treatment of anaemia in HIV-positive children. The risk of death remained high among young children, especially those age one to two years, who were malnourished or anaemic, even at high CD4% or counts. At older ages, CD4% or CD4 count was better at identifying low-risk children if weight-for-age and haemoglobin were included in the assessment.
While conceding that defining thresholds for these markers is difficult due to their complex inter-relationship, the researchers conclude that “for effective care of HIV-infected children in resource-limited settings, prevention and treatment of malnutrition and anaemia need to be integrated within routine clinical management.”
Need for better lab tests
“The strong effect of CD4% and CD4 cell count over and above other markers underlines the importance of access to low-cost laboratory monitoring,” write the study authors. They also note that while both CD4% and CD4 count were similarly prognostic, CD4 count is difficult to interpret in young children due to the dramatic decline in early in life. “The financing of currently available CD4% technology and the development of more affordable and feasible technology for resource-limited settings is therefore a priority,” they urge.
Informing guidelines
In agreement with current guidelines, the 3Cs4kids study supports the use of CD4% and CD4 count as predictors of short-term risk of death. The researchers add that any African trials of treatment initiation strategies should include growth markers and haemoglobin and that the timing of nutritional of nutritional care and antiretroviral treatment should be clarified.
Reference
3Cs4kids Analysis and Writing Committee. Markers for predicting mortality in untreated HIV-infected children in resource-limited settings: a meta-analysis. AIDS 22:97 – 105, 2008.
Anti-HIV treatment reduces TB incidence in Spain
Antiretroviral therapy and tuberculosis (TB) control measures have helped reduce the incidence of tuberculosis in Spain in recent years, according to data from GEMES, the Spanish Multicenter Study Group of HIV Seroconverters published in the November 30th 2007 edition of AIDS.
HIV increases the risk of TB disease through reactivation of latent infection as the immue system declines or by accelerating the progression of recently acquired infection. Therefore the availability of effective antiretroviral therapy since the mid-1990s is likely to have had an impact on the epidemiology of TB in HIV-infected individuals.
Although this are good data about the incidence of TB in resource-limited countries, there is less information about the incidence of the infection in industrialised countries.
Spain has a high incidence of HIV compared to other countries in Western Europe and intravenous drug use (IDU) has been a major route of HIV transmission. Before the HIV epidemic, Spain had the second highest TB rate of Western Europe in the general population. IDUs, irrespective of their HIV status, are also exposed to high levels of TB infection. As a result of this, Spain has seen a large overlap of both the HIV and TB epidemics leading to high rates of HIV–TB co-infection.
Using data from GEMES, an established Spanish nation-wide cohort of HIV-infected individuals with well known dates of seroconversion from the 1980s to the present day, researchers analysed the incidence and determinants of tuberculosis in HIV-seroconverters before and after the introduction of effective antiretroviral therapy. Furthermore, all HIV-infected persons with clotting disorders (PCD) from three of the largest haemophilia units in Spain were analysed.
Information on sociodemographic characteristics (age, sex) as well as clinical and immunological data (number and type of AIDS events, antiretroviral treatments prescribed, lymphocyte CD4 cell count, HIV viral load, vital status and cause of death) were collected. All transmission categories were included: IDU, men who have sex with men (MSM), heterosexuals and PCD/people with haemophilia.
Calendar year at risk was divided into three periods (before 1992, between 1992–1996 and 1997–2004) reflecting the availability of different antiretroviral therapies before the introduction potent anti-HIV therapy in Spain in 1996. Between 1992 and 1996 only AZT, ddC, 3TC, d4T and ddI were available for the treatment of HIV and AIDS. Incident tuberculosis was calculated as cases per 1000 person-years. In this study TB diagnoses were culture proven in 85% of cases.
The proportional hazard model was used to determine the factors associated with the risk of developing TB taking into account the following variables: gender, exposure category, age at seroconversion, and calendar period.
Data from 2238 HIV-seroconverters (1874 men and 364 women) between the 1980s and 2004 were analysed. Overall, 51.9% were infected with HIV via IDU, 27.4% were PCD and 20.6% were infected by sexual transmission, of which 14.7% were heterosexuals.
By December 2004, 173 (7.7%) patients had developed TB (55.5% pulmonary, 35% extra-pulmonary and 10% in both locations) giving an overall rate of 7.3 cases per 1000 person-years (95% confidence interval [CI], 6.3–8.5). TB was the first AIDS-defining condition in 147 patients (85%), second in 19 cases (11%) and third in six cases (3.5%). Median time from HIV seroconversion to TB disease was 5.6 years.
The median CD4 cell count at TB diagnosis was 80 cells/mm3, indicating a profound state of immune suppression. After the introduction of effective antiretroviral therapy, the median was 182 cells/mm3. The majority (106; 61.2%) of the patients that developed TB had not received any antiretroviral treatment and 135 out of 173 (78%) were IDUs.
Incident tuberculosis was higher in IDUs, 12.3 per 1000 person-years compared with persons infected sexually, 3.8 per 1000 person-years (P < 0.001), and persons with clotting disorders (PCD), 2.7 per 1000 person-years (P < 0.001).
Highest tuberculosis rate, 44 per 1000 person-years, were observed prior to 1997 in IDUs infected with HIV for eleven years.
A decreasing tuberculosis incidence trend was observed from 1995 in all categories. TB rates in the era of effective anti-HIV therapy (5.6 per 1000 person-years) were significantly lower than before 1997 (8.9 per 1000 person-years). TB rates before and after the introduction of potent antiretroviral therapy were 18.09 and 8.68 cases per 1000 person-yers for IDUs, 8.18 and 2.22 cases per 1000 person-years for sexually transmitted HIV and 3.43 and 0 cases per 1000 person-years for PCD, respectively. The reductions in the hazard of TB for each of the transmission categories were 48%, 27% and 100%, respectively. For PCD, no new TB cases were observed after 1997.
The study showed a 69% reduction in the incidence of TB among HIV-seroconverters from all transmission categories from 1997 onwards, (RH, 0.31; 95% CI, 0.17–0.54; P < 0.001). Before 1997, the risk of tuberculosis increased with time since HIV seroconversion, whereas it remained nearly constant in the era of potent anti-HIV therapy. After 1997, TB did not increase with longer duration of HIV infection but peaked around the fifth to seventh year in the IDU and sexually transmitted HIV groups, and decreased thereafter.
Among the 65 TB cases observed since the introduction of effective anti-HIV therapy, 52 (80%) were IDU and 41of the 65 (63%) were not taking antiretroviral therapy. The remaining 24 patients developed TB despite having started anti-HIV therapy.
Women had a 38% lower risk of TB compared to men. IDUs showed a three times higher risk of developing TB and PCD had a 60% lower risk in comparison with people infected through sexual transmission.
The authors conclude, “Our results suggest that in the period between 1997 and 2004, improvements in the immune status among those receiving HAART and/or a reduction in the environmental risk of TB transmission must have taken place. Forty percent of patients from GEMES cohorts had been initiated on HAART, so it is likely that antiretroviral therapy may be responsible for a large proportion of the observed reductions in TB, as it has been for other AIDS-defining conditions.”
As the decreasing trends in TB were observed just before the introduction of effective anti-HIV therapy in Spain they also note that TB control programmes may have also played a part.
Reference
Roberto Muga et al. Changes in the incidence of tuberculosis in a cohort of HIV-seroconverters before and after the introduction of HAART. AIDS 21:2521–2527, 2007.
Siapa yang mau percaya dengan UNAIDS?
Stephen Lewis damns UNAIDS over statistics revision; diverts from the tragedy of AIDS
Rob Dawson, Thursday, November 29, 2007
www.aidsmap.com
In a passionate speech at the World Health Editors Network in London, a former United Nations Special Envoy for AIDS in Africa and Co-Director of AIDS-Free World, Stephen Lewis, warned that a recent UNAIDS document reporting decreased HIV infections has “undermined public confidence in the reliability of the figures, introducing completely unnecessary levels of doubt, contention and confusion”. Describing the UN as “stubborn and sloppy”, he expressed concern that the report does nothing to convince the world that we are “billions and billions of dollars behind, when it comes to funding all the components of the pandemic, from orphans to second line drugs.”
In its latest report, UNAIDS cut the number of infections worldwide to about 32.7 million, down from its estimated 39.5 million in 2006. Rather than a reduction based on decreased rates of infection, the new figure was mainly due to fixing flawed statistics from previous reports. The former data collection methods relied heavily on “sentinel-site surveillance” which extrapolates data gathered at prenatal clinics. An assumption was made that the rate of HIV in the general population would be similar to the rate among pregnant women in urban clinics. This year the UN attributed more of their calculations to national surveys and blood-testing.
While it’s good news that fewer people are infected than previously thought, there was concern that the dramatic re-representation of the figures would result in diverted resources from an epidemic still in desperate need of funds.
“For years, knowledgeable epidemiologists have been telling the UN that the figures were too high. They didn't whisper their criticisms: they wrote books and articles,” Lewis said. “But the UN chose a course of delay and dithering. It can never admit that it's wrong. So finally, and predictably, came the moment of truth: the result is an overall prevalence rate that is lower by almost seven million than last year's estimate.”
Lewis also expressed anger that the report did not address the human tragedy and focused too much on statistics.
“The new estimates confirm a continuing apocalypse for sub-Saharan Africa: 22.5 million infections, 61% of them women, 68% of world-wide infections, 76% of all deaths, 11.4 million orphans. This is where the focus must be, this is where it should always have been; not a report cluttered by mathematical adjustments so that virtually every story that’s written begins with the news of a statistical volte-face. If the recording of data had been more scrupulous all along, we could have welcomed this report,” he said. “Instead, all of us have to run to the trenches to remind the world that more money is still desperately needed.”
Lewis also highlighted several flaws in the data which could lead to yet another recalculation. For example, the narrative evidence of the report states repeatedly that Mozambique has shown no decrease in infection rates yet later asserts that Mozambique is one of the six countries in the world that has most significantly contributed to the reduced numbers seen in the report. No data on Mozambique is set out conclusively in the report.
In conclusion, Lewis stressed that more should be done no matter what statistical calculation is applied to the figures.
“Whether it's 40 million or 33 million, this plague continues to ravage humankind. I simply do not believe that the United Nations has done everything it can possibly do to turn the tide,” he said.
Experts endorse European plan to reduce late HIV diagnosis
An international meeting of clinicians, patient advocates and policy makers has endorsed plans to promote earlier diagnosis of HIV infection throughout Europe, in order to reduce the numbers who are still diagnosed with AIDS or die from it in Europe.
The HIV in Europe 2007 conference was convened by the Cophenhagen University AIDS Programme, WHO Europe, AIDS Action Europe, the European AIDS Clinical Society, the European AIDS Treatment Group and numerous other groups involved in HIV care and advocacy in the EU.
The meeting’s Call for Action, endorsed by around 100 organisations present at the two-day meeting in Brussels earlier this week, urges all key stakeholders involved in HIV care to:
Acknowledge that earlier diagnosis and care is urgently needed to improve the lives of people living with HIV and reduce transmission
Develop more precise estimates – size, characteristics, etc – of the undiagnosed population
Communicate the benefits of earlier care and reduce perceived barriers to testing
Implement evidence-based testing and treatment guidelines in every country
Commit the necessary political, financial and human resources for their timely implementation.
Why is there a need for earlier HIV diagnosis in Europe?
Around 35% of people with HIV in the European Union are unaware of their HIV status – approximately 250,000 people – but across the wider European region that includes the Russian Federation and Ukraine, the number undiagnosed rises to 1.2 million.
Taking data from UNAIDS and national surveys, Professor Andrew Phillips and colleagues at University College and Royal Free Medical School, London, modelled the ongoing effects of late diagnosis in Europe.
In Western Europe, estimates Professor Phillips, 16,000 people are undiagnosed and in need of treatment now, because they have a CD4 cell count below 200. Ten thousand people are likely to die by 2009 due to late diagnosis, and throughout the wider European region – including the Russian Federation and Ukraine – 120,000 could die by 2009 if they are not diagnosed with HIV. If all these people could be diagnosed and receive treatment according to European guidelines, at least 90,000 lives could be saved, the model estimates.
According to Prof. Andrew Phillips, earlier diagnosis and treatment could also have substantial effects on the rate of new infections
Late presentation for treatment – that is, HIV diagnosis late in the course of infection, when treatment should start without delay - varies across Europe and by risk group.
Twenty-two per cent of gay men in the UK are still diagnosed late, compared with 47% of heterosexual men (predominantly African men).
A recent large Italian study found a 37% rate of late diagnosis, defined as the onset of an AIDS-defining illness less than six months after an HIV diagnosis, and similar rates of late diagnosis, however it is defined, have been found in other western European countries.
In France the proportion who start late – 35% - did not change between 1997 and 2005, and survival among late presenters hasn’t improved either, despite a growing range of drugs to treat HIV infection.
These figures become all the more worrying, experts agree, because new information published over the past year has made it clear that HIV treatment needs to start earlier than current guidelines recommend in order to produce the best results.
Current UK guidelines (due to be updated in early 2008) recommend that all individuals should start treatment before their CD4 cell count falls below 200 cells, but recently issued guidelines from the European AIDS Clinical Society recommend treatment for all patients with a CD4 cell count below 350.
If that threshold was implemented in the UK, the number of people diagnosed late would rise from 33% to 57%.
Barriers to earlier HIV diagnosis
Why is late diagnosis such a problem in the best-funded health systems in the world, when HIV treatment is highly effective and becoming so much easier to tolerate?
One reason is that people perceive HIV infection as a disease affecting only those with many sexual partners, according to Prof. Christine Katlama, and don’t see one or two sexual partners each year as posing much of a risk. But over ten to twenty years, the number mounts up, she said, providing more opportunities for infection.
For many heterosexuals, the problem is that they have never considered themselves to be at risk, but for gay men and Africans from countries seriously affected by AIDS, the reasons for not testing may be to do with denial, and lack of knowledge about the availability of effective treatment.
For Africans the barriers to testing are especially high. “If you’re relying on a small close-knit community for all kinds of emotional and financial support, fear of being cast out from that community may be enough to prevent you from testing,” said Ibidun Fakoya, a researcher from London’s Royal Free Hospital.
Other barriers commonly cited by migrants across Europe are lack of entitlement to free health care, together with confusion about what health care they might be entitled to. Concern about the confidentiality of test results is also widespread.
Opt out
For many, the major barrier to early diagnosis is simply never being offered the option of an HIV test. In the UK for example, individuals who don’t give blood, have a baby or attend an STI clinic may never be offered an HIV test even if they have a high risk of HIV exposure.
In the United States public health officials are trying to improve the rate of HIV diagnosis by routinely testing all adults at least once, predominantly through primary care but also through routine testing in emergency rooms and upon any admission to hospital. People with high risk behaviour – including all gay men – are being encouraged to test annually.
But in Europe there is widespread doubt that such an approach would be either cost-effective or achievable. Instead European HIV experts are trying to agree on a list of indicator conditions that should lead to HIV testing in the general population, including sexually transmitted infections, tuberculosis, lymphoma, oral thrush, hepatitis B or C, lymphadenopathy and any AIDS-defining condition.
The move is partly triggered by a widespread awareness that people diagnosed late with HIV have often been seen by general practitioners with health problems that might give rise to suspicion.
However, the broader spectrum of complaints that often bedevil people with milder immunosuppression, such as bacterial pneumonia, shingles, dermatitis and other skin problems haven’t made it onto the list of indicator diseases because HIV specialists do not know how frequently they occur in HIV-positive people, nor the likelihood that a person presenting with one of these conditions will be HIV-positive.
Widespread testing does take place in Eastern Europe, often without obtaining consent. Every year 25 million people are estimated to be tested, according to Gennady Roshchupkin of the International Harm Reduction Network, but only 14% of injecting drug users have been tested. “When it comes to opt in or opt out, our countries have no concept of opt-in testing,” he told the meeting.
Major barriers to learning one’s HIV status still exist in the form of discrimination against people with HIV, and pose major disincentives to testing, especially for migrant communities and in Eastern Europe.
However the increasing use of the criminal law to prosecute people for reckless transmission of HIV also drew attention at the meeting, and participants agreed that legal sanctions against transmission were harming HIV prevention efforts and reinforcing reluctance to test.
Keith Alcorn, Friday, November 30, 2007
www.aidsmap.com
Study finally backs up conventional wisdom: VCT does reduce risky sex in Africa
Kenyans attending rural and urban primary healthcare-based voluntary counselling and testing (VCT) services reported significant reductions in the number of sexual partners, fewer sexually transmitted infection symptoms, and increased condom use – albeit from a very low base – six months following an HIV antibody test, according to the results of an observational study of behaviour change and life events published in Sexually Transmitted Infections, published online on 8th November.
The investigators conclude that their study “suggests that future health centre-based VCT services emphasising prevention outcomes should be considered in counselling and testing packages, alongside [diagnostic counselling and testing] and antiretroviral treatment programmes, to ensure that substantial prevention opportunities are not missed.”
The findings offer a more optimistic assessment of VCT's impact on sexual behaviour than a study conducted in Zimbabwe, presented in June at the South African AIDS Conference, which showed that a negative HIV test result was associated with an increase in risky sexual behaviour, and that offering VCT had no impact on HIV incidence.
The findings also provide the most solid evidence to date backing the frequently repeated assertion that VCT is a cornerstone of HIV prevention.
However, this study – nested in a pilot study of integrating VCT into government primary healthcare centres in Kenya – took place in 1999, before antiretroviral therapy and diagnostic counselling and testing were in place in Kenya, and when VCT existed predominantly in a few urban private clinics, NGOs and district hospitals.
Out of a possible 743 consecutive clients seeking VCT at three primary health centres – two in the rural Thika district and one in urban Nairobi – throughout 1999, 540 (73% of those eligible) were enrolled equally across clinics. A total of 14.7% tested HIV-positive.
The average time to follow-up was 7.5 months (median 6.9 months). Overall, 401 (74%) were successfully followed up, although the investigators concede that the follow-up group – of whom 12.3% had tested HIV-positive – under-represents HIV-positive clients, female HIV-positive clients in particular. Clinic clients reporting multiple sex partners also tended to be lost to follow-up.
Of note, the majority (65.5%) of clients perceived very little or no chance of testing HIV positive, with only a loose correlation between their expectations and the HIV result itself. Notably, three-quarters (27/36) of clients who thought that they were ‘likely’ or ‘very likely’ to test positive ended up testing HIV negative.
Sexual activity and partner numbers
During their VCT visit, the majority of clients from all clinics (98% of women and 90% of men) reported either one primary partner or no sexual activity over the preceding two months.
A total of 16% (24% of men and 8% of women) reported two or more partners in the preceding six months. At follow-up, this reduced to 6% (10% of men and 2% of women; p<0.001).
’ABC’ and condom use
Condoms were the least popular prevention measure reported at the VCT visit. Just one third of clients reported ever using a condom, and only 6% reported using condoms consistently with their primary partner; none used condoms consistently with non-primary partners. Consequently, 95% of casual sex acts and 77% of commercial sex acts reported were unprotected.
Immediately after receiving their result, 47% clients reported that they planned to be faithful to one partner, whereas just 23% planned to use condoms. At follow-up, only half of those planning condom use had actually used them. Yet, 85% of clients reported that condoms were easily accessible to them, and only 6% said that they could not afford condoms.
Although condom use remained low at follow-up, sexual intercourse was more often protected compared to baseline (from 95% to 89%; p=0.021). This was primarily due to negative attitudes towards condom use, which improved but remained high at follow-up. Embarrassment in using condoms fell from 42% to 33% (p<0.001) and the number of clients who agreed with the idea that ‘condoms symbolise unfaithfulness’ fell from 54% to 44% (p<0.001).
Sexually transmitted infection symptoms
Forty per cent of VCT clients reported STI symptoms in the preceding six months, and around two-thirds of those reporting symptoms had sought treatment.
At follow-up, significantly fewer STI symptoms were reported (40% vs. 15%; p<0.001.) However, the investigators note that one of the limitations of their study was that there were no biological measures of STIs.
Impact on disclosure
Perhaps unsurprisingly, the investigators found that post-VCT there were very high rates of disclosure by HIV-negative clients, but much lower rates for HIV-positive clients. “This,” write the investigators, “highlights the importance of seeking improved strategies for disclosure for HIV-positive clients—for example, using couple counselling.”
Before receiving results, 93% planned to disclose if they were HIV-positive. However, at follow-up, 55% of HIV-positive and 82% of HIV-negative clients had disclosed the results of their test. There were no reported differences in disclosure by gender. The investigators note that there was a high baseline rate of physical abuse or neglect by family – 8% of clients reported these – but that these were essentially unaltered by an HIV-positive result.
Study limitations and cautions
The investigators point out several limitations to this study. Notably, there was no control group; social desirability bias may have led to under-reporting of risky behaviours; the study population under-represented HIV-positive clients; and participants may not have been representative of VCT attendees in Kenya generally.
In addition, the investigators note, “these data were collected in the pre-antiretroviral era; any recommendations must be made cautiously, as behaviour may have changed with antiretroviral availability.”
Nevertheless they argue that the availability of treatment “has also moved the focus towards diagnostic testing, and it remains important to consider missed opportunities for prevention. Many VCT clients failed to perceive their higher HIV risk compared with the general public. There was also poor correlation between individual risk perception and HIV result, making counselling and testing a vital tool in this population.”
Discussion and conclusion
The investigators write, “at this time of emphasis on HIV treatment, it is critically important to focus on primary HIV prevention strategies. This study found that clients planned risk reduction after pre-test counselling and showed significant changes in sexual behaviour at follow-up. These findings are in line with randomised controlled trials suggesting that primary health centre services can help primary prevention efforts. Ongoing monitoring for negative impacts is recommended.
“The challenge to policy makers,” they conclude, “is to now weigh the prevention benefits of VCT against the possibility that it may not offer greatest efficiency in increasing treatment uptake. This study suggests that future health centre-based VCT services emphasising prevention outcomes should be considered in counselling and testing packages, alongside DCT and antiretroviral treatment programmes, to ensure that substantial prevention opportunities are not missed.”
Reference
Arthur G et al. Behaviour change in clients of health centre-based voluntary HIV counselling and testing services in Kenya. Sex Transm Infect 83:541–546, 2007.
Edwin J. Bernard, Tuesday, November 27, 2007
www.aidsmap.com
CMV Retinitis Diagnosis and Treatment Strategy
Introducing a CMV Retinitis Diagnosis and Treatment Strategy in Thailand
Thailand is one of few developing countries to provide HAART nationwide [55], treatment being available at 800 hospitals [56] and some health centers [57]. The national protocol for CMV retinitis diagnosis and treatment includes screening of patients with CD4 count below 100 cells/μl, induction therapy with intravenous ganciclovir, and maintenance therapy with either intravenous or intraocular ganciclovir [58]. In practice, however, diagnostic capacity only exists in specialist centers, and there is no allocation in the national budget for this disease, although it is planned for 2008.
In Kuchinarai District, Northeastern Thailand—the country's poorest region—200 people with HIV receive HAART through the district hospital in a project supported by MSF since 2002. Most patients first present with advanced disease, 17% having been diagnosed with CMV retinitis following visual symptoms. Regular screening by indirect ophthalmoscopy is being introduced, performed by two general medical practitioners following initial training at a tertiary referral hospital. Their initial training (one week only) could not provide complete skills, but was sufficient to create a referral system whereby patients with suspected CMV retinitis are referred to the tertiary center for confirmation of diagnosis and intraocular ganciclovir injection.
However, many patients live up to 25 km from the hospital and public transport in this district is lacking. For earlier diagnosis, we are introducing screening where the first patient contact often occurs—at the health station level. Screening is done by the hospital's general practitioners during monthly visits. Clinical management of CMV retinitis needs to be integrated into HIV care at both the district hospital and health station level, and availability of systemic treatment of CMV retinitis with oral valganciclovir would make this far more feasible.
Valganciclovir is available from Roche for transplant patients in Thailand, but the cost for treating CMV would be $US9,398 (Assumptions for price calculation: Induction phase of 900 mg twice daily for 21 days, followed by maintenance phase of 900 mg once daily for three months. A three month supply of a comparable off-patent product such as acyclovir is available for $US89 on the international market (median price). In negotiations with MSF's Access to Essential Medicines Campaign, Roche has offered $US1,800 for use in AIDS patients by nongovernmental organizations in sub-Saharan African countries and least developed countries. However, Thailand was excluded from this offer.
(David Wilson and A. Kace Keiluhu)
Plos Journal: medicine.plosjournasl.org
Nearly a third of HIV-positive people in London report discrimination, often from healthcare staff
Almost a third of HIV-positive individuals surveyed in London have experienced HIV-related discrimination, according to a study to be published in the December edition of AIDS and Behaviour (currently in press). Half of the individuals who reported discrimination said that it had involved healthcare staff.
HIV-related discrimination (or the fear of such discrimination) can have far-reaching consequences, including a failure to test for HIV or access HIV care. Some research even suggests that discrimination may contribute to HIV risk behaviour.
Tackling HIV-related discrimination was a key aim of the UK’s national HIV strategy, which was published in 2001. And in 2006 the UK government has published a draft action plan on address the stigma and discrimination attached to HIV. As part of this plan, NAM, the publisher of aidsmap.com, was commissioned by the Department of Health to write a booklet on HIV, stigma and discrimination. It can be read here.
But there is very little UK research on the number of HIV-positive individuals who have experienced HIV-related discrimination. Investigators from London’s City University and the Centre for the Study of Sexual Health and HIV at Homerton University Hospital therefore designed a study to determine the extent to which people with HIV living in London have been discriminated against because of their HIV infection and by whom. The study was also designed to see if there were any factors associated with reporting such discrimination.
The study ran between June 2004 and June 2005 and patients attending NHS HIV outpatient clinics in north east London aged 18 or over were eligible for recruitment.
Individuals were asked if they had ever been discriminated against because they had HIV. If they answered ‘yes’ they were asked to say by whom. There was also an opportunity for individuals to describe their experience of discrimination.
To establish the factors associated with discrimination, study participants were asked to provide details of their age, sex, ethnicity, sexual orientation, immigration status, country of birth, and relationship status. They were also asked to say how many years they had been living with diagnosed HIV infection, if they were taking antiretroviral therapy, if they had experienced any treatment side-effects, or if they thought their body shape had changed as a consequence of taking anti-HIV drugs.
Because the investigators wanted to see if discrimination was related to risky sexual behaviour, the study participants were asked to say if they had had anal or vaginal sex in the previous three months and with whom.
A total of 2680 patients were eligible for inclusion in the study and 1687 completed and returned questionnaires.
Results
Gay men (758 individuals), black African heterosexual women (480 patients), and black African men (224 individuals) comprised 87% of the study sample and were included in the investigators’ analysis. Although questionnaires were returned by white heterosexual men and women and patients of other black and Asian ethnicities their numbers were too small for statistical analysis.
The investigators found that 30% (414) of their study sample reported discrimination because of their HIV status. In initial ‘univariate’ analysis, gay men were statistically more likely to report discrimination than black African women or men (34% vs. 28% vs. 21%, p < 0.001).
Subsequent ‘multivariate analysis’ showed that reporting HIV-related discrimination was significantly associated in all three groups with an increasing number of years since HIV diagnosis and the body showing signs of HIV (p < 0.05).
After controlling for number of years since HIV diagnosis and the body showing signs of HIV infection, the investigators found that gay men, black African women and black African men were equally likely to report that they had been discriminated against because of their HIV infection.
Of the 414 people who reported experiencing HIV-related discrimination, 403 answered the question, ‘By whom?’ Just under half (49.6%) said the discrimination had come from healthcare staff, meaning that 14% of the entire study sample had experienced discrimination because of their HIV infection from a healthcare professional.
Additional information about the experience of discrimination was provided by 316 individuals and 54 people specifically mentioned HIV. Discrimination from healthcare staff (for example, “the dentist refused to treat me”), employers (for example, “I lost out on career opportunities when they found out I was HIV-positive”), and from family or friends (for example, “I was rejected from my family because of HIV), were mentioned.
A further 72 people did not specifically mention HIV, but they experienced discrimination from the same sources.
Mental health and discrimination
After controlling for the number of years since HIV diagnosis and HIV-related body shape changes, experiencing HIV-related discrimination was significantly associated with depression and suicidal thoughts amongst gay men (p < 0.05) and was of border-line significance for black African heterosexual women (p = 0.06).
Discrimination and sexual risk
There was no relationship between experiencing discrimination because of HIV and reporting unprotected anal or vaginal sex.
Investigators’ comments
“In a diverse sample of people living with HIV surveyed in London in 2004 or 2005, nearly a third said they had been discriminated against because of their HIV infection. Of those who reported HIV-related discrimination, almost a half said this had involved a health care worker”, comment the investigators.
Because gay men and black African men and women were equally likely to report HIV-related discrimination, the investigators believe that such discrimination is a function of “exposure risk”. They explain, “specifically, the number of years you have lived with HIV or whether the body is showing signs of HIV, rather than ethnicity, gender or sexual orientation.”
Some limitations with the study are acknowledged by the investigators. The research looked at self-report of HIV-related discrimination and therefore was reliant upon individuals’ subjective experience of discrimination and willingness to report such discrimination. The investigators also note that they were unable to tell if respondents were reporting perceived or actual discrimination. Furthermore, small numbers meant that it was not possible to examine the HIV-related discrimination experienced by some patient groups, although the investigators believe “it is likely that they will also experience HIV-related discrimination.”
But the investigators believe the study had significant strengths, not least that its recruitment from NHS HIV treatment centres means that it was representative of the HIV-affected population in the UK. Furthermore, the sample size was large and diverse.
“Our findings highlight the urgent need for the Department of Health implement its action plan for combating HIV-related discrimination in the UK, inside as well as outside the NHS”, conclude the investigators.
Reference
Elford J et al. HIV-related discrimination reported by people living with HIV in London, UK. AIDS and Behaviour (in press), 2008.
Michael Carter, Friday, November 30, 2007
www.aidsmap.com
Many HIV patients believe their doctors stigmatize them
Physicians might want to be extra careful about how they
treat HIV-infected patients —not just in the clinical sense but in the way they
behave toward them.
Even the perception that physicians are stigmatizing
patients for carrying the virus that causes AIDS can discourage these
individuals from seeking proper medical care, according to a new UCLA study.
The study, published in the August issue of the
peer-reviewed journal AIDS Patient Care and STDs, found that up to one-fourth
of patients surveyed in the Los
Angeles area reported feeling stigmatized by their
health care providers. This perception was also linked to low access to care
among these patients, a large proportion of whom are low-income and minorities.
"Whether or not it is actual stigmatization is hard to
measure, because it's coming from the patients that we interviewed," said UCLA
researcher Janni J. Kinsler,
the study's project director and lead researcher. "The point is that these
people feel that way, and that's bad enough, because they're less likely to
seek the care they need."
The study results were based on surveys of 223 HIV-positive
individuals in Los Angeles County, with initial
baseline interviews taking place between May 2004 and June 2005 and follow-up
interviews conducted six months later, from November 2004 to December 2005. Of
the respondents, 80 percent were male, 46 percent were African American and 40
percent were Latino. Nearly three-quarters had a high school education or less,
half had annual incomes below $8,000 and 46 percent did not have insurance. In
addition, 54 percent of the patients reported that they became infected through
homosexual contact, 30 percent through heterosexual contact and 16 percent
through intravenous drug use.
There are two types of stigma: external, or "public," stigma
and personal, or "perceived," stigma. The latter refers to individuals'
anticipated fears of societal attitudes or discrimination because their HIV
infection.
Researchers questioned 223 patients during the baseline
interviews and 171 during the follow-up. They were asked the following
questions about stigmatization:
Since you contracted HIV, has any health care provider:
·
Been uncomfortable with you?
·
Treated you as inferior or in an inferior
manner?
·
Preferred to avoid you?
·
Refused to serve you?
Patients were also asked six questions related to their
access to health care: whether they had gone without medical care due to
expense, if medical care was conveniently located, whether they could obtain
medical care whenever they needed it, if they had easy access to medical
specialists, if emergency care was easily obtainable and if they could be
admitted to hospitals with no trouble.
The researchers found that at baseline 26 percent of the
patients reported at least one of the four types of perceived stigma from a
health care provider, and 19 percent reported the same at follow-up. Also, 58
percent claimed low access to care on at least one of the six relevant
questions at baseline, as did 57 percent at follow-up.
"Most importantly, we found that those who perceived stigma
from a health care provider had more than twice the odds of reporting low
access to care, even after examining the effect prospectively and adjusting for
a host of sociodemographic and clinical
characteristics," the researchers said.
Researchers noted the significance that perceived stigma
"could greatly affect [patients'] use of needed medical services, including
antiretroviral therapy." Because of this, patients may seek medical care only
when their illness has progressed to a more severe stage, leading to more
intensive medical interventions, hospitalization and earlier death.
The next step is to investigate whether physicians are in
fact stigmatizing these patients, Kinsler said.
In addition to Kinsler, researchers
included Mitchell Wong, Jennifer N. Sayles and William Cunningham of UCLA, and
Cynthia Davis of Charles R. Drew University of Medicine and Science in Los Angeles.
The U.S. Health Resources and Services Administration, the
U.S. Agency of Health Quality Research, the National Center
on Minority Health and Health Disparities, and the National Institute on Aging
funded this study.
How to deliver good adherence support: lessons from round the world
How to deliver good adherence support: lessons from round the world
by Keith Alcorn
The first-line antiretroviral regimens now being taken in resource-limited settings are based on nevirapine or efavirenz. Resistance to either drug can develop very easily if doses are missed, and studies have shown that patients need to take at least 95% of doses in order to have a good chance of maintaining viral suppression. That means missing no more than three doses a month for a twice-daily regimen, and maintaining that level of adherence year after year.
Given that many treatment programmes are reporting that between 65% and 80% of patients still have undetectable viral load after several years of treatment, it is clear that these demanding levels of adherence are being widely achieved.
However, maintaining good adherence among patients requires vigilance. Research in Nigeria conducted by the University of Abuja Hospital and the University of Maryland Institute of Human Virology found that one in five patients reported adherence of less than 95% (judged by how promptly people came back for more tablets, the so-called refill rate) (Farley).
At Kericho Hospital in Kenya, around one in twenty patients on ARVs reported missing doses within the previous three days. In 29% of cases it was because they had run out of tablets and couldn’t afford to get to the clinic to get more. But in another 29% of cases it was because, after a median ten months of treatment, they felt better and didn’t see the need to carry on taking medication.
This study found that the single most important factor in determing whether patients kept taking their medication was the belief, cited by 80% of adherent patients, that ARVs work. However only 29% mentioned that they knew adherence was critical in making ARVs work.
This edition of HATIP reviews recent experiences in the field of adherence support, highlighting some of the practicies that are making a difference worldwide.
Individual barriers to good adherence
A systematic review of all the published studies looking at adherence in developed and developing countries found a striking universality of barriers to adherence – and facilitators of good adherence among individuals around the world (Mills 2006).
Barriers
Facilitators
Forgetting to take tablets or too busy
Fear of disclosure
Disruptive to everyday life or away from home
Don’t understand treatment
Side effects – real and anticipated
Depression / hopeless
Concurrent substance abuse
Suspicious of medicines
Belief that the drugs work/seeing positive results
Disclosure/social support
Twice daily dosing or less, fewer pills
Good relationship with health care provider
Katherine Semrau of Boston University reported at the 2007 HIV Implementers’ meeting on reasons why women in Zambia refused or stopped HIV treatment. Her findings were strikingly consistent with findings from qualitative research among Africans living in the United Kingdom.
Reasons for not starting when treatment offered
Reasons for stopping treatment
“ARVs are bad”
Stigma
Fear of divorce
“Not enough food”
Fear of permanent lifestyle changes such as avoiding alcohol
Taking medicines indefinitely when there is no cure
Lack of accurate information about the drugs and HIV treatment aims
Her focus groups told her that people stopping or refusing treatment were repeatedly receiving inaccurate information from trusted figures such as pastors, traditional healers, teachers and respected elders which undermined the authority of information received from nurses, doctors and community-based organisations. A classic notion in circulation was the belief that ARVs must be taken with food to be effective.
It was clear, she said, that treatment information needs to be adjusted to the cultural context, and it was important to identify the information gatekeepers who are providing misleading information and work to re-educate them.
For further information please visit the HATIP section of aidsmap
Female Condoms: The Missing Prevention Method
In 2006, only one female condom was available for every 100 women worldwide. This disturbing fact won't surprise anyone who's ever tried to locate female condoms The fact that I had to traverse the city to find a female condom points to greater problems than those presented for sexual spontaneity. This experience starkly highlights a failure to market and distribute one of the most effective prevention methods, and the only available female-controlled method, against the sexual transmission of HIV.
When used correctly and consistently, the female condom is as effective as the male condom in preventing HIV. Additionally, the female condom remains the only new form of STI prevention developed since the advent of the AIDS epidemic. Since that time, the world has experienced a feminization of the disease : worldwide, 17.3 million women over 15 are infected with HIV, and 76% of HIV-positive youth in sub-Saharran Africa are female. While the majority of new HIV infections occur in developing countries, women in the United States are not exempt from the scourge of this disease: AIDS is the leading cause of death for African American women aged 25-34. Such conditions demand a female-controlled prevention method.
To address this demand, public and private entities like USAID and the Bill and Melinda Gates Foundation have begun investing millions of dollars into research on microbicides —undetectable gels and creams that women could apply vaginally to protect themselves from the sexual transmission of HIV. Because they are undetectable and could be applied prior to intercourse, microbicides present distinct advantages for women with partners who oppose protection. However, UNAIDS estimates that a microbicide won't be ready for general use for another five to seven years. Additionally, the recent halting of two phase III microbicide trials due to product failure reminds us that these yet-to-be-developed technologies are still a promise of the future and further underscores the immediate need to enable women to protect themselves with prevention technologies currently available.
The unit cost of female condoms—approximately $0.60—is often cited as a barrier to distribution. However, estimates predict that increasing female condom distribution from the present 20 million-per-year to 200 million-per-year would decrease their cost by two-thirds, making them cost-competitive with male condoms. To date, donors have spent $163 million on microbicide research. According to a study published by Johns Hopkins University, one-fifth that amount could purchase over 50,000,000 female condoms and prevent as many as 32,000 new HIV infections in South Africa. Imagine the savings to South Africa's healthcare system if the country had 32,000 fewer HIV cases. Imagine the savings for human life.
This is not a matter of putting research budgets against procurement budgets, but rather of doing everything in our power to fund the distribution of an effective HIV prevention method that women and men worldwide can start using now.
Female condoms provide an alternative to the male condom and allow women to bring a protection option to the table (or bed, if you will). Additionally, research has shown that couples' ability to switch between male and female condoms leads to an increase in the total number of protected sexual acts. Most importantly, female condoms are available now—they can start curbing the spread of HIV and saving lives today.
Organizations and communities must demand access to female condoms. Zimbabwe only began importing female condoms after women's groups presented their government with 30,000 women's signatures demanding access to them. Such grassroots and community action needs to take place around the world. By enabling and empowering women to protect themselves and their partners with female condoms, we can begin saving lives and curbing the spread of HIV today.
This article that written by Lauren Sisson, and also had been edited again for this website
Feb 14 2007
Breast-feeding benefits seen in HIV-infected women
WASHINGTON, March 29 (Reuters) - African women infected with the AIDS virus cut the risk of transmitting it to their babies when they fed them exclusively breast milk and not also formula, animal milk or solid food, a study found on Thursday.
Researchers in South Africa, writing in the Lancet medical journal, tracked 1,372 HIV-infected women and found a 4 percent risk of postnatal transmission of the human immunodeficiency virus to babies fed only breast milk for six months after birth.
The infants who were breast-fed but also given baby formula or animal milk were almost twice as likely to get the virus from the mother as those consuming breast milk alone, the study found. Babies fed solid foods in addition to breast milk were nearly 11 times more likely to become infected, it found.
The researchers cited a biological reason that might explain the findings. They said the mucous membrane within the intestines may serve as a barrier to HIV infection, and that breast milk could reinforce and protect that lining.
The study also found that the death rate by 3 months of age for babies who were exclusively breast-fed was less than half that of infants who received infant formula alone.
Fifteen percent of babies whose HIV-infected mothers did not breast-feed them died by age 3 months, compared with 6 percent of the babies whose mothers fed them exclusively through breast-feeding, the study found.
The study indicated that for women in impoverished areas where AIDS is most prevalent, the health benefits of breast milk appeared to outweigh the risk of passing on HIV through breast-feeding.
PROS AND CONS
Experts say breast milk provides nutrients an infant needs for the first months of life as well as antibodies that can protect against bacterial and viral infections.
But the breast milk of HIV-infected women may contain the virus and risk infecting the child. Thus, under ideal conditions, experts believe HIV-infected women should not breast-feed babies. But in sub-Saharan Africa, the epicenter of the AIDS epidemic, conditions often are not ideal.
Since infant formula is mixed with water before being given to the baby, woman living in communities with impure water and poor sanitary conditions risk exposing babies to waterborne illnesses that can cause life-threatening diarrhea or other ailments.
The study was led by Dr. Hoosen Coovadia and Dr. Nigel Rollins of the University of KwaZulu-Natal in South Africa.
Rollins said an estimated 150,000 to 350,000 babies were infected with HIV by their mothers through breast milk annually. The study's findings suggest that if infected women living in impoverished areas exclusively breast-fed their babies, somewhere around 50,000 to 100,000 lives could be saved annually, Rollins said.
"For the health and well-being of her child, exclusive breast-feeding is more than likely going to protect the child both from transmission and the other risks to her child's survival," Rollins said in a telephone interview.
More than 25 million people have died of AIDS since the incurable disease was first recognized in 1981. About 40 million people now live with HIV, most in sub-Saharan Africa.
The researchers were not sure why the addition of solid food particularly heightened the mother-to-child transmission risk, but noted the larger, more complex proteins in such foods may help enable the virus to slip through the gut wall or otherwise facilitate viral entry.
The MTCT-Plus Initiative: Reaching Individuals with Early HIV Disease through Family
BACKGROUND: Providing HIV treatment in less developed countries is a global priority. Most programs focus exclusively on antiretroviral therapy (ART) and on patients with advanced HIV disease. In contrast, the MTCT-Plus Initiative has established comprehensive family-centered HIV programs in less developed countries.
METHODS: In 8 African countries and in Thailand, 11 programs were established. HIV-infected women were identified by programs for prevention of mother-to-child transmission; they, their children, and their partners were invited to enroll in MTCT-Plus. Programs provide HIV care (including ART), lab tests (CD4 count, infant diagnosis), medication procurement, and adherence/prevention/psychosocial support. Adult eligibility for ART includes: WHO stage IV; CD4 <200; or WHO stage II/III with CD4 <350 cells/mm3. Demographic, clinica, and laboratory data are collected with standardized forms. Adherence is assessed via self-report.
RESULTS: We enrolled 1088 individuals between February and August 2003, including 765 adults (75% women, 25% partners/others) and 323 children (88% of last pregnancy); 42% of women were enrolled during pregnancy and 56% postpartum. Adults had baseline median CD4+ cell count of 296 cells/mm3 (range 1 to 1741) and were: 63% WHO stage I, 19% stage II, 15% stage III, and 3% stage IV; 6% had prior TB. Among 323 children enrolled, 53(16%) had confirmed HIV and 84% were of indeterminate status. Of 53 children with confirmed HIV, 32% were of most recent pregnancy. Based on MTCT-Plus ART eligibility criteria, 41% adults were eligible for ART while only 30% would have been eligible by WHO criteria. Mean follow-up at the time of this report is 3.2 months. At follow-up, 29% of adults and 57% of HIV-infected children were on ART; 92% of adults on ART reported adherence with all their doses at their last assessment; 29% of adults were on cotrimoxazole; and 20% on isoniazid preventive therapy.
CONCLUSIONS: MTCT-Plus has successfully enrolled women identified through pMTCT programs with their families in preventive, supportive, and therapeutic services including ART. Patients are at earlier HIV disease stages than in other programs and more patients are ART eligible using MTCT-Plus criteria.
By committing to long-term family-based care, early identification of medical and psychosocial needs, and providing ongoing preventive, supportive, and therapeutic services (including ART), the MTCT-Plus Initiative provides a unique model for expanding access to HIV care in less developed countries.
The MTCT-Plus Initiative: Reaching Individuals with Early HIV Disease through Family-focused HIV Care and Treatment in Less Developed Countries.
El-Sadr WM, Rabkin M, Abrams EJ, Day J, Hardy T, Myer L, Rosenfield A.
11th Conf Retrovir Opportunistic Infect Febr 8 11 2004 San Franc CA Conf Retrovir Opportunistic Infect 11th 2004 San Franc Calif. 2004 Feb 8-11; 11: abstract no. 893.
Harlem Hosp., New York, NY, USA
Parallel MTCT-Plus Programs: Experiences and Lessons Learned from Thailand
BACKGROUND: A successful Thai Red Cross AIDS Research Centre (TRCARC) prevention of mother-to-child transmission program initiated in 1996 using public donation money has led to a continuation program called "Treat the Parents and Save the Orphans," the TRC MTCT-Plus program in 2003. TRCARC was also selected as 1 of the 13 sites around the world to demonstrate the concept of Columbia University (CU)'s MTCT-Plus program. Both MTCT-Plus programs were run together while keeping as minimal differences between them as possible.
METHODS: In February 2003, we started enrolling Thai HIV-infected women and families in 4 hospitals. Both programs used the MTCT-Plus protocol modified to go along with the country's guidelines. To prove that both programs can be run together without creating double standard of care, we compared the percentages of enrollees received basic HIV care between the 2 programs using chi-square test.
RESULTS: Protocol modification were: inclusion criteria-CU allowed no more than 50% of women be "old" (delivered July 2002 to January 2003), while TRC aimed to enroll as many "old" (any woman from previous TRC pMTCT since 1996) women as possible; co-payment with waiver-to encourage enrollees to be self-supporting for the cost of their own CD4 test and ARV eventually, all enrollees were asked to co-pay for CD4 test and male partners were asked to co-pay for ARV; ARV follow-up-we replaced 8 weekly follow-up visits by telephone follow-up in week 1, 3, 5, and 7 to minimize difficulties of enrollees being absent from work, which was seen to enhance adherence rather than to risk ARV side effects. Enrollment as of September 2003 at CU sites included 42 old and 54 new (currently pregnant) women, in a total of 216; whereas TRCARC included 98 old and 24 new women, in a total of 211. [table: see text]
CONCLUSIONS: MTCT-Plus programs no matter using money from public donation or international funding agencies, can be integrated and coordinated to maximize benefit to the country's health care system.
Phanuphak N, Teeratakulpisarn S, Apornpong T, Tasai C, El-Sadr W, Phanuphak P.
11th Conf Retrovir Opportunistic Infect Febr 8 11 2004 San Franc CA Conf Retrovir Opportunistic Infect 11th 2004 San Franc Calif. 2004 Feb 8-11; 11: abstract no. 894.
Thai Red Cross AIDS Res. Ctr., Bangkok, Thailand and 2Mailman Sch. of Publ. Hlth., Columbia Univ., New York, NY, USA
PMTCT from Research to Reality — Results from a Routine Service
Abstract
Objectives. Assessment of the efficacy of a prevention of mother-to-child transmission (PMTCT) programme in a routine service setting in comparison to a research environment.
Design. Descriptive study over a 13-month period utilising retrospective data obtained from hospital records complemented by prospective data on a sample of patients enrolled in a study to determine an affordable HIV diagnostic protocol for infants.
Setting. Routine PMTCT service at Coronation Women and Children's Hospital (CWCH) situated in Johannesburg and affiliated to the University of the Witwatersrand.
Subjects. Pregnant women known to be HIV infected who delivered at CWCH from 1 October 2001 to 31 October 2002.
Outcome measures. The HIV transmission rate to infants, which reflects nevirapine (NVP) delivery and infant feeding practices, and follow-up rates of perinatally exposed children.
Results. Of the 8 221 deliveries, 1 234 (15%) occurred in women known to be HIV infected. HIV transmission rates of 8.7% at 6 weeks and 8.9% at 3 months of age in the study population verifies the high rate of NVP administration and the ability of women to formula-feed their babies and abstain from breast-feeding. More than one-third of infants never return for follow-up and more than 70% are lost to follow-up by 4 months of age.
Conclusions. The low HIV transmission rate confirms the efficacy of this routine service PMTCT programme. HIVinfected children are not being identified for medical management as part of PMTCT follow-up. It is imperative that record keeping is improved to facilitate ongoing monitoring.
GG Sherman, et.al. S Afr Med J 2004; 94: 289-292.
First HIV and Viral Hepatitis Training Course in Surabaya, East Java, 2007
On February 3 and 4, the Indonesian Medical Association (IMA) HIV Secretariat, together with support from ASHM and the AusAID Indonesia HIV/AIDS Prevention and Care Project (IHPCP), conducted the first HIV and Viral Hepatitis Training Course in Surabaya, East Java. The course was attended by around 40 participants, including specialists, community and hospital based doctors, nurses, community educators and PLWHA advocacy groups. The course attracted participants from Java, Sulawesi, Lombok and other islands who were coming to Surabaya to attend the 3rd National HIV & AIDS Conference from February 5 to 8.
The course program was developed collaboratively by the IMA team, ASHM International Division and IHPCP. Due to the high rate of drug injecting in Indonesia, coinfection of HIV and hepatitis is a major concern for many health care providers and educators. The course was co presented with Dr Peter Pigott, from ASHM, and virology specialists, Dr Rino Gani and Dr David Mulyono and Dr Hariadi Moeljosudirjo, a hepatologist from Malang, East Java. A number of course participants presented case studies over the two days. The course has been evaluated very well by the participants and follow up support and contact will be maintained by the IMA. Plans are now being discussed to conduct similar courses through other IMA offices in Indonesia, as there has been a great deal of interest from people who were not able to attend the Surabaya program.
The National HIV & AIDS Conference was held at the Shangri La Hotel and drew over 1500 delegates from across the country. A number of ASHM members also attended and gave presentations. The number of delegates and the wide ranging symposia topics, together with workshops, abstract driven sessions and poster displays were evidence of an increasing awareness and capacity to address the challenges of HIV in Indonesia today. Those challenges include complex ARV treatment issues, including co infection with TB, viral hepatitis, malaria and other illnesses, as well as increasing the capacity for early diagnosis of opportunistic infections and appropriate treatment options.
Following the Surabaya meeting, we traveled to Jakarta for a round of meetings and workshops with our colleagues from IMA, as well as the National AIDS Commission, and visits to some of the hospital based HIV clinics. During this time a Memorandum of Understanding was agreed between ASHM and the IMA. This will guide collaboration and support between the two societies over the coming years and it is hoped that Dr Fachmi Idris, IMA President will visit ASHM during the IAS meeting in July for a formal exchange of documents. It was also agreed during this visit that the IMA will produce an Indonesian edition of the ASHM monograph, Coinfection HIV and Viral hepatitis a guide for clinical management. This is the first time that an ASHM resource will be produced in another country for national distribution and ASHM is very pleased to support this activity.
ASHM is very grateful to the IMA and IHPCP staff for their ongoing advice and support during this visit, particularly given that these meetings occurred during the Jakarta flood emergency. A number of our colleagues' homes were severely flooded, and all medical services were occupied with the health and emergency needs of people affected. We are very grateful that our meetings and workshops were able to proceed at this time.
ASHM and the IMA are working closely to develop collaborative support programs. A delegation of our Indonesian colleagues will attend the IAS Conference in July 2007 as well as some of the satellite meetings, and participate as presenters in this year's International Short Course in HIV and Related Issues.
Dampak epidemi HIV-AIDS tidak mudah ditanggulangi, adanya masalah koinfeksi pada orang-orang yang terkena HIV. Problema koinfeksi HIV dengan HCV, HBV, TB, serta penyakit infeksi lainnya mendorong penanganan yang lebih komprehrensif. Koinfeksi tidak saja dapat memperburuk status kesehatan orang dengan HIV, juga HIV itu sendiri mempercepat situasi dampak buruk infeksi lainnya.
To address this demand, public and private entities like USAID and the Bill and Melinda Gates Foundation have begun investing millions of dollars into research on microbicides —undetectable gels and creams that women could apply vaginally to protect themselves from the sexual transmission of HIV. Because they are undetectable and could be applied prior to intercourse, microbicides present distinct advantages for women with partners who oppose protection. However, UNAIDS estimates that a microbicide won't be ready for general use for another five to seven years. Additionally, the recent halting of two phase III microbicide trials due to product failure reminds us that these yet-to-be-developed technologies are still a promise of the future and further underscores the immediate need to enable women to protect themselves with prevention technologies currently available.
The researchers cited a biological reason that might explain the findings. They said the mucous membrane within the intestines may serve as a barrier to HIV infection, and that breast milk could reinforce and protect that lining.
BACKGROUND: Providing HIV treatment in less developed countries is a global priority. Most programs focus exclusively on antiretroviral therapy (ART) and on patients with advanced HIV disease. In contrast, the MTCT-Plus Initiative has established comprehensive family-centered HIV programs in less developed countries.
On February 3 and 4, the Indonesian Medical Association (IMA) HIV Secretariat, together with support from ASHM and the AusAID Indonesia HIV/AIDS Prevention and Care Project (IHPCP), conducted the first HIV and Viral Hepatitis Training Course in Surabaya, East Java. The course was attended by around 40 participants, including specialists, community and hospital based doctors, nurses, community educators and PLWHA advocacy groups. The course attracted participants from Java, Sulawesi, Lombok and other islands who were coming to Surabaya to attend the 3rd National HIV & AIDS Conference from February 5 to 8.
The National HIV & AIDS Conference was held at the Shangri La Hotel and drew over 1500 delegates from across the country. A number of ASHM members also attended and gave presentations. The number of delegates and the wide ranging symposia topics, together with workshops, abstract driven sessions and poster displays were evidence of an increasing awareness and capacity to address the challenges of HIV in Indonesia today. Those challenges include complex ARV treatment issues, including co infection with TB, viral hepatitis, malaria and other illnesses, as well as increasing the capacity for early diagnosis of opportunistic infections and appropriate treatment options.
ASHM is very grateful to the IMA and IHPCP staff for their ongoing advice and support during this visit, particularly given that these meetings occurred during the Jakarta flood emergency. A number of our colleagues' homes were severely flooded, and all medical services were occupied with the health and emergency needs of people affected. We are very grateful that our meetings and workshops were able to proceed at this time.
