[procaare] AIDS 2006: Daily News Report 15 August 2006

["ProCAARE" <procaare@healthnet.org>]

AIDS 2006: Daily News Report 15 August 2006
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aidsmap.com daily news reports from World AIDS Conference - Tuesday

    * The Two Bills 
    * HIV prevention 
    * Illness and death in Africa 
    * Undiagnosed illness in Asia and the Pacific 
    * MRSA - an emerging infection amongst HIV-positive patients in the US 
    * Nutrition 

The Two Bills

HIV prevention, illness and nutrition provided the broad subjects for news coverage on aidsmap.com from the first full day of the Sixteenth International AIDS Conference in Toronto. These subjects were also the <http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1793/>focus of a discussion between the world's richest man, Bill Gates and former US President Bill Clinton on Monday morning. Both men, who are well recognised public faces in the international fight against HIV, set out what they saw as their priorities to end the AIDS epidemic: prevention that goes beyond abstience, wider treatment access, fighting stigma to increase testing and the wider issues of poverty and hunger. Bill Clinton, who as US President was master of the sound-bite, summed their goals: to "stop people dying who don''t have to."

HIV prevention

Pre-exposure prophylaxis (PREP) - HIV-negative people taking antiretroviral drugs on a daily basis to prevent infection with HIV - made the news again on Monday at the Toronto AIDS Conference. Bill Gates highlighted PREP as a promising method of HIV prevention in his speech at the opening of the conference. A study conducted in Africa found that fewer women who took the anti-HIV drug tenofovir (Viread) become infected with HIV than women who took the dummy placebo. There were 731 women in the trial equally divided into two arms and two of the women receiving tenofovir become infected with HIV versus six of the women taking the placebo. These numbers were too small for the difference to regarded as statistically significant. There were encouraging safety results from the study, and taking tenofovir was not shown to produce liver or kidney abnormalities. Two large studies looking at the safety and efficacy of PREP will start later this year. Both of the studies will use tenofovir combined with FTC (emtricitabine, Emtriva) as lab studies show it may be a better PREP candidate than tenofovir alone. One of the studies will be conducted in Botswana, the other in Peru. But there are concerns about PREP studies, particularly the potential to "seed" resistance to key anti-HIV drugs in at-risk populations; and access to antiretroviral therapy for individuals who become infected.


Illness and death in Africa

Taking potent anti-HIV therapy can mean a longer, healthier life. But HIV-positive individuals taking antiretroviral therapy still have an increased risk of death compared to their HIV-negative peers. This is true in both richer countries and resource limited settings. Now a study has found that African patients who started HIV treatment with an extremely weak immune system (a CD4 cell count below 50 cells/mm3, and who receive their HIV care at poorly-resourced rural clinics, have the greatest risk of death. Nine clinics from Kenya were included in the study, which included patients who started antiretroviral therapy between 2001 and 2005. The researchers found that the deaths occurred soon after anti-HIV therapy was initiated (an average of only eight weeks), and were significantly higher amongst individuals with low CD4 cell counts (below 200 cells/mm3) prior to starting treatment. They also found that anaemia and low haemoglobin were associated with an increased risk of death. Death was also significantly more likely for rural patients - possibly because they had poorer access to healthcare facilities and staff. South African research presented to the conference also showed that patients who had certain infections prior to starting antiretroviral therapy had an increased risk of death. Researchers from Durban found that individuals who had oral candidiasis before starting HIV therapy were over 150% more likely to have died within a year of starting HIV treatment. Oral candidiasis or thrush, is usually considered a very mild infection and can occur in patients with CD4 cell counts as high as 250 cells/mm3. The findings of this study should remind d
immune damage seriously. The investigators also found that patients who had crypotococcal meningitis before initiating antiretroviral treatment also had an increased risk of death. However, this finding is hardly surprising as this infection is usually only seen in patients with a CD4 cell count below 50 cells/mm3.

Undiagnosed illness in Asia and the Pacific

Dementia, peripheral neuropathy and depression are common amongst HIV-positive patients in Asia and the Pacific, but often go undiagnosed, according to the results of a study presented to the Toronto conference. These conditions had been thought to be uncommon in the region, but the results of this study show that they are, in fact, under-diagnosed. The study involved over 650 HIV-positive patients and 161 HIV-negative controls in Thailand, Indonesia, China, Malaysia and the Asia-Pacific region. The HIV-positive study population was in relatively poor health, with approximately two-thirds having an AIDS diagnosis, median CD4 cell count was a little over 200 cells/mm3 (the level at which HIV treatment should be initiated) and 65% were taking potent HIV treatment. Dementia was diagnosed in 12% of HIV-positive patients, peripheral neuropathy in 19% and depression in 33%. Use of "d" drugs - d4T (stavudine, Zerit ) and ddI (didanosine, Videx) is a recognised risk-factor for peripheral neuropathy, and patients in this study who took these drugs were found to have a significantly increased risk of developing this painful side-effect. On the basis of their findings, the investigators estimate that 1.5 million antiretroviral-treated people in the Asia-Pacitific region could have peripheral neuropathy. Older age and a low CD4 cell count were identified as risk factors for de mentia, and only 5% of patients with depression were taking antidepressants.

MRSA - an emerging infection amongst HIV-positive patients in the US

For the last few years, the mainstream media has often provided sensational coverage of the "untreatable" super bug MRSA (methicillin-resistant staph. aureus) and the infection even became a major issue in the UK general election of 2005. A study presented to the Toronto conference demonstrated that MRSA is increasingly becoming an issue for HIV-positive individuals. Researchers from San Diego found that HIV-positive individuals were 18 times more likely than the general HIV-negative population to become infected with community-acquired (i.e. whilst not in hospital) MRSA. Their study involved 425 men, and 25 (6%) were diagnosed with community acquired-MRSA. All the cases were after 2002. When the investigators looked at risk factors for the infection, they found that it was associated with recent infection with syphilis and the use of antibiotics to treat syphilis. There have recently been outbreaks of syphilis in many European and US cities, particularly amongst gay men. However, because this study included US military personnel it was not possible to enquire about sexual behaviour as gay people are not allowed to serve in the US military. nterestingly, most of the cases of MRSA seen in this study involved abscesses on the buttocks or scrotum. The trimming or shaving of pubic hair has become fashionable in recent years, notably amongst gay men, and the investigators asked if this might be implicated in the development of the infection. Nora Crum-Cianflone said this was "plausible."


Nutrition

Supplementation

Taking selenium supplementation improves response to anti-HIV therapy, according to a study conducted in Nigeria and presented to the conference. The study included 340 patients who, in addition to receiving potent antiretroviral therapy, were randomised to receive 200mg of selenium supplementation a day or a placebo. Patients who received selenium had a greater increase in their CD4 cell count; fewer opportunistic infections; fewer hospital visits; gained more weight; and experienced a greater increase in haemoglobin levels. The investigators stress, however, that selenium supplementation should be seen as a useful adjunct to potent HIV therapy - not as its replacement.

Food supplementation and antiretroviral therapy

Hunger and poverty are widespread amongst HIV-positive people in southern Africa, and a study conducted in Zambia has found that HIV-positive individuals who received a corn-soya food supplement enriched with micronutrients gained more weight and had better adherence to their treatment than patients who did not. However, the investigators found that food supplementation did not increase CD4 cell count. The researchers believe that further studies are needed to determine the usefulness of food supplementation for people receiving HIV therapy.


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