[procaare] AIDS 2006: Daily News Report 17 August, 2006

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Daily News Report 17 August, 2006
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aidsmap.com daily news reports from World AIDS Conference - Thursday

    * Double trouble 
    * HIV and cancer 
    * HIV and TB 
    * HIV and sexual health 
    * HIV and children 


Double trouble

 
Even with potent HIV therapy, HIV remains a life-affecting, and potentially life limiting illness. But often it?s not the only issue health or social issue that HIV-positive people live with. As research presented to the Sixteenth International HIV Conference in Toronto shows, many HIV-positive individuals also live with other serious health problems, such as malignancies, and TB. 

What would be normally seen as natural human activities can involve additional problems for HIV-positive individuals. Contrary to what some people may like to believe, most HIV-positive individuals don?t take a vow of celibacy or have condoms miraculously grafted onto their genitals on the day of their diagnosis, but remain sexually active, and often have enhanced sexual health needs. 

And simply being young can mean additional problems if you?re HIV-positive, not least because there are fewer drugs available for the treatment of HIV in children than adults, and for children in some poorer settings, an essential prerequisite for safe HIV treatment, clean drinking water, can?t be taken for granted.


HIV and cancer

Thanks to effective <http://www.aidsmap.com/en/docs/91F79F48-9F8E-4654-998C-85E6AAC039A5.asp/>antiretroviral therapy there has been a dramatic fall in the incidence of the AIDS-defining cancers <http://www.aidsmap.com/en/docs/E88DEA43-B5AF-438F-B645-8621CA8E709B.asp/>Kaposi?s sarcoma and <http://www.aidsmap.com/en/docs/1B254B27-A9E9-47E3-ADDD-5767DE08F311.asp/>non-Hodgkin?s lymphoma amongst HIV-positive people with access to HIV treatment. 

But cancers remain a concern for HIV-positive people, particularly <http://www.aidsmap.com/en/docs/F6A1473B-4C6C-4078-8E2E-61A84E7BC3D6.asp/>anal cancer and <http://www.aidsmap.com/en/docs/B80BF36D-935D-490B-9A19-A4CDFA67B574.asp/>cervical cancer caused by high-risk genotypes of the human papilloma virus (HPV). Data on both were presented to the Toronto conference. 


Anal cancer

<http://www.aidsmap.com/en/news/5F6E2774-1574-4CB3-A44E-4D1E13D1AA7F.asp/>An analysis of the French Database of HIV shows that the the incidence of anal cancers has increased since potent HIV therapy became available. In the era before effective HIV therapy there were 16 cases of anal cancer per 100,000 patient years; this had increased to 62 per 100,000 years in the period 1999 - 2003. 

Over two-thirds of the cases were in gay or bisexual men. The probably of surviving three years after a diagnosis of anal cancer was 75%. The investigators believe that the increase in anal cancer since the introduction of effective HIV therapy is because people who are infected with high-risk types of HPV are living long enough to progress to it. They call for HIV-positive patients to be <http://www.aidsmap.com/en/news/410F03B6-334E-43BA-A829-4C12844B958B.asp/>screened for early signs of anal cancer


Cervical cancer

<http://www.aidsmap.com/en/news/7BC19012-D429-4FDA-997A-E88D1D1D9475.asp/>93% of HIV-positive in a Zambian study had cell abnormalities or lesions indicative of pre-cancerous or cancer changes in the cervix. In addition, 85% of the 150 in the study were infected with strains of HPV associated with a high-risk of cervical cancer. 

The researchers believe that the high prevalence of cervical abnormalities seen in the study could be partly due to the low <http://www.aidsmap.com/en/docs/D2596CD3-B444-4F86-AE85-DDC5F048CEF3.asp/>CD4 cell counts of women in the study (mean 161 cells/mm3), and although 75% of the women were taking antiretroviral therapy, most had only been doing so for six months or less. Infection with high risk types of HPV increased the risk of cervical abnormalities twelve-fold. 

The investigators emphasised the need to develop cervical cancer screening and treatment programmes for HIV-positive women in resource-limited countries.


HIV and TB

<http://www.aidsmap.com/en/docs/767DC946-F6F0-4F16-8A23-8D29B92975B1.asp/>Tuberculosis (TB) is the leading cause of illness and death amongst HIV-positive individuals around the world, and a substantial amount of research into TB prevention and treatment has been presented to the Toronto conference.


TB testing

The<http://www.aidsmap.com/en/docs/1D686403-3A64-4FBE-A9AF-80630CBE4971.asp/> ELISPOT TB test appears to be a useful diagnostic tool for use in HIV-positive patients, <http://www.aidsmap.com/en/news/9F5BB3FA-D7B1-4DAC-89AF-B3C5035CB503.asp/>studies conducted in Africa suggest. A skin test has previously been used to tests for TB, but often proved inaccurate because it failed to generate a reaction in immune suppressed HIV-positive people and because the use of the BCG TB vaccination yielded a high rate of false-positives. The ELISPOT test looks for a cellular immune response to TB. 

A Zambian study showed the value of the ELISPOT test for diagnosing TB in HIV-positive patients, but conducted in South Africa suggested that the new test was of little added value when the HIV-positive status of an individual was known and the skin test interpreted accordingly.


Incidence of TB

<http://www.aidsmap.com/en/news/FDFDB15D-FC69-4CAE-8D9E-246C4A72570D.asp/>The incidence of TB may actually increase after HIV therapy has started. Studies conducted in Uganda and Senegal showed that the incidence of the infection increased during the early months of HIV therapy. In the Ugandan study the incidence of TB was approximately 8 per 100 patient years during the first six months of HIV treatment. In the study conducted in Senegal, the incidence of the infection was 6.4 cases per 100 years during the first year of HIV treatment, before falling dramatically to 1.4 cases per 100 patient years for the third year of treatment. The researchers speculate the <http://www.aidsmap.com/en/docs/9E3CEB70-9AED-45D2-88C8-7790F2738DBA.asp/>immune reconstitution inflammatory syndrome may have contributed to the early increases in TB observed.


HIV and sexual health

 
The overwhelming majority of HIV-positive individuals worldwide became infected with the virus through unprotected sex and remain sexually active after their HIV diagnosis. HIV-positive patients often have worse sexual health than their HIV-negative peers, and sexually transmitted infections are known to increase the risk of onward transmission of HIV. Unsurprisingly, a significant amount of research is focused on the sexual activity and health of HIV-positive people.


Sexually transmitted infections and the risk of HIV infection

<http://www.aidsmap.com/en/news/EA5DF51F-FF0C-4217-A8B2-78C0AEC461C8.asp/>HIV-negative individuals in a sexual relationship with somebody who is HIV-positive are significantly more likely to become infected with HIV if they acquire a sexually transmitted infection, research has shown. The study was conducted in Rwanda and involved 1509 couples where once partner was HIV-positive, the other HIV-negative. A total of 46 individuals became infected with HIV, and both men and women who had symptoms suggestive of a range of sexually transmitted infections often occurred in the period before HIV was diagnosed. But the researchers note the sexually transmitted infections cannot explain all the HIV infections.


Treatment for HSV

<http://www.aidsmap.com/en/docs/96BE1839-0AF9-4C7D-A5DA-322ABDA4AFF6.asp/>Herpes simplex virus-2 (HSV-2) has been linked in epidemiological and biological studies to HIV transmission. <http://www.aidsmap.com/en/news/DDB34A0A-26BD-4575-B19F-BFDAAD5C873F.asp/>Two studies presented to the Toronto conference have shown daily treatment with the anti-herpes drug <http://www.aidsmap.com/en/docs/50EB3B3C-4B77-4602-8650-D43AB24241DE.asp/>valaciclovir leads to a significant reduction in genital shedding of HIV and plasma HIV <http://www.aidsmap.com/en/docs/902FFCC5-6B1C-42C3-9548-CE361439B58D.asp/>viral load amongst women not taking anti-HIV therapy. Valaciclovir therapy also lead to a significant reduction in genital shedding of HIV in women taking HIV treatment. But the investigators emphasised that individuals receiving anti-HIV therapy still needed HIV prevention information, as 66% of women were still potentially<http://www.aidsmap.com/en/docs/DD62B951-E826-49D9-AD7E-A9E53F506D56.asp/> infectious, as they were shedding significant amounts of HIV in their genitals almost six months after initiating HIV treatment.


Circumcision

Male circumcision has become a very hot topic in HIV prevention, <http://www.aidsmap.com/en/news/62B0B005-7FCC-4515-848E-8FF8EAF78951.asp/>and one researcher presented a mathematical model suggesting that circumcision could cut new HIV infections by almost two-thirds, even if condom use fell to 50%. Further research suggested that circumcision could be cost effective, lead to an increase in condom use, ands ?acceptable? to female partners. But circumcision as an HIV-prevention measure is controversial. Some view it as coercive and other as potentially undermining more traditional HIV prevention methods based on the correct and consistent use of <http://www.aidsmap.com/en/docs/A69D22D5-4640-4C87-8A68-FE633C0C0DAD.asp/>condoms. 


HIV and children

Less is known about the use of antiretrovirals in children and there are fewer anti-HIV drugs available for use in children than in adults (in both richer and resource limited countries). But research presented to the International AIDS Conference shows that this is gradually changing.


Nucleoside backbone

Children who took an NRTI backbone of abacavir (Ziagen) and 3TC (lamivudine, Epivir) as part of their anti-HIV regimen had better viral suppression and growth than children who took backbones comprising either AZT (zidovudine, Retrovir) and 3TC or AZT and abacavir. <http://www.aidsmap.com/en/news/8CF43257-638E-43A3-B420-713150AF5CE8.asp/>In a five year study, European researchers also found that virtually no children who only took a dual NRTI combination experienced a satisfactory virological outcome. 

Anti-HIV drugs can be difficult for children to take, but the investigators note that abacavir/3TC were easy to make up in liquid, but did stress the need for a fixed-dose pill suitable for use in children.


Tipranavir for children

Many HIV-positive children have very limited treatment options, <http://www.aidsmap.com/en/news/49AD093E-7B78-4DB3-916B-140C81F56A13.asp/>therefore the news that an early clinical trials has shown that an oral solution of <http://www.aidsmap.com/en/docs/49C00072-27A8-4D8A-8CA3-75CC648D0F4C.asp/>tipranavir (Aptivus), boosted by <http://www.aidsmap.com/en/docs/3D08FB32-E5C7-4F0B-BAF8-502290079BDE.asp/>ritonavir (Norvir) is safe and effective in highly treatment-experienced children will be welcomed. The study involved 115 children who took the study medication with an optimised background regimen. Two weight-based doses of tipranavir/ritonavir were studied. After 48 weeks, 46% of children taking the lower-dose had a viral load below 400 copies/ml as did 40% of children taking the higher dose. A little over a third of children in both arms achieved a viral load below 50 copies/ml. Better adherence, and higher genetic sensitivity were associated with a virological response. 4% of children experienced severe side-effects, the most commonly reported being nausea, vomiting and diarrhoea.


Fixed dose generic formulations for children

<http://www.aidsmap.com/en/news/F9419934-F805-4748-91BF-E333CA7B9620.asp/>Two fixed dose water dispersible tablets including quarter and half doses of nevirapine, lamivudine and stavudine have been developed by the generic manufacturer, Ranbaxy. The two formulations have been approved by the Indian government and submitted to WHO for inclusion on the pre-qualification list. 

The Bioequivlanece data were presented to the conference for the formulations. But delegates expressed concern that the studies were conducted in adults, and emphasised that the new Ranbaxy products would not be suitable for use in children weighing under 10kg. The company said it would be developing additional products for the lowest weight infants. 

The fixed-dose tablets must be dispersed in water, therefore its essential that infants provided with these products have clean<http://www.aidsmap.com/en/docs/F39FED95-458F-45AF-AAEF-7190E35BF3F6.asp/> drinking water.


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