Kenya: Counselling, not alarm device, had best effect on ART adherence

Via aidsmap, by Carole Leach-Lemens

Patients in Nairobi, Kenya getting intensive early adherence counselling when starting antiretroviral therapy were 29% less likely to have poor adherence and 59% less likely to have virological failure compared to those getting no counselling Michael H Chung and colleagues reported in a randomised, controlled trial published in the March issue of PLoS Medicine.

The positive effects of counselling on adherence were seen immediately after starting antiretroviral therapy and maintained throughout the18 month follow-up period. Use of an alarm device had no effect on adherence or virological outcomes. Public health concerns that scale-up of antiretroviral treatment in sub-Saharan Africa would lead to poor adherence and widespread drug resistance have been proven wrong, note the authors.

The authors conclude “as antiretroviral treatment clinics expand to meet an increasing demand for HIV care in sub-Saharan Africa, adherence counselling should be implemented to decrease the development of treatment failure and spread of resistant HIV.”

Read the rest

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

AFRICA: Need for systematic HIV drug resistance testing

 via PlusNews

HIV is a tough enough diagnosis, but when one contracts a strain of HIV resistant to some life-prolonging medicines, treatment options are limited. A new study has found that transmitted HIV drug resistance may be on the rise in Africa, and the authors warn that unless resistance surveillance is increased, the continent's treatment programmes could suffer.

The study, led by the International AIDS Vaccine Initiative (IAVI) in five African countries, found that the prevalence of transmitted drug resistance in Rwanda, Uganda and Zambia was considerably higher than previously reported. Of 408 people studied in Kenya, Rwanda, South Africa, Uganda and Zambia, 19 had transmitted resistance mutations. Resistance prevalence rose considerably during the study in Zambia and remained high throughout the study in Entebbe (Uganda).

"The message to take away from this study is the urgent need for regular drug resistance surveillance, which we currently do not have," said Omu Anzala, head of the Kenya AIDS Vaccine Initiative. "If we can see transmitted resistance in such a small study then there could be much more going around."

"We saw what has happened with malaria over the years, with resistance developing against several drugs. We need to move quickly to ensure governments are aware and are implementing drug resistance surveillance to prevent the same thing happening with ARVs," he added.

In 2009 Kenya launched a five-year national plan on HIV drug resistance, prevention, monitoring and surveillance.

A separate study in 2010 by PharmAccess African Studies to Evaluate Resistance (PASER), a project of the PharmAccess Foundation, a Dutch health NGO, found that nearly 6 percent of patients about to start HIV treatment for the first time already had resistance to standard first-line ART.

Read the rest

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Africa: Need for systematic HIV drug resistance testing

via IRIN PlusNews

HIV is a tough enough diagnosis, but when one contracts a strain of HIV resistant to some life-prolonging medicines, treatment options are limited. A new study has found that transmitted HIV drug resistance may be on the rise in Africa, and the authors warn that unless resistance surveillance is increased, the continent's treatment programmes could suffer.

The study, led by the International AIDS Vaccine Initiative (IAVI) in five African countries, found that the prevalence of transmitted drug resistance in Rwanda, Uganda and Zambia was considerably higher than previously reported.

Of 408 people studied in Kenya, Rwanda, South Africa, Uganda and Zambia, 19 had transmitted resistance mutations. Resistance prevalence rose considerably during the study in Zambia and remained high throughout the study in Entebbe (Uganda).

"The message to take away from this study is the urgent need for regular drug resistance surveillance, which we currently do not have," said Omu Anzala, head of the Kenya AIDS Vaccine Initiative. "If we can see transmitted resistance in such a small study then there could be much more going around."

Read the rest.

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

HIV, transmitted drug resistance, and the paradox of preexposure prophylaxis

Proceedings of the National Academy of Sciences of the United States of America
by Virginie Supervie, J. Gerardo García-Lermb, Walid Heneine, and Sally Blower

Excerpt:

If the results from the phase III trials ending in 2010 show moderate to high efficacy, then PrEP interventions could be implemented in the near future in resource-rich countries. We have shown PrEP could significantly reduce transmission in the MSM community in San Francisco even if efficacy is only moderate, provided coverage is high and risk compensation does not occur. High coverage may be attainable: recent surveys indicate ~70% of MSM in California and in Massachusetts have stated they would be willing to take PrEP on a daily basis if it were proven safe and effective (41, 42); furthermore, MSM reporting risky behaviors were more likely to anticipate using PrEP (42). Although our quantitative results are specific to the MSM community in San Francisco, the qualitative insights we have gained are applicable to any high-risk community where treatment has been readily available for many years and current levels of transmitted resistance are already high.

Read the entire article.

HIV, Transmitted Drug Resistance, and the Paradox of PrEP

Via National Academy of Sciences, by Virginie Supervie, J. Gerardo García-Lerma, Walid Heneine, and Sally Blower

The administration of antiretrovirals before HIV exposure to prevent infection (i.e., preexposure prophylaxis; PrEP) is under evaluation in clinical trials. Because PrEP is based on antiretrovirals, there is considerable concern that it could substantially increase transmitted resistance, particularly in resource-rich countries. Here we use a mathematical model to predict the effect of PrEP interventions on the HIV epidemic in the men-who-have-sex-with-men community in San Francisco. The model is calibrated using Monte Carlo filtering and analyzed by constructing nonlinear response hypersurfaces. We predict PrEP interventions could substantially reduce transmission but significantly increase the proportion of new infections caused by resistant strains. Two mechanisms can cause this increase. If risk compensation occurs, the proportion increases due to increasing transmission of resistant strains and decreasing transmission of wild-type strains. If risk behavior remains stable, the increase occurs because of reduced transmission of resistant strains coupled with an even greater reduction in transmission of wild-type strains. We define this as the paradox of PrEP (i.e., resistance appears to be increasing, but is actually decreasing). We determine this paradox is likely to occur if the efficacy of PrEP regimens against wild-type strains is greater than 30% and the relative efficacy against resistant strains is greater than 0.2 but less than the efficacy against wild-type. Our modeling shows, if risk behavior increases, that it is a valid concern that PrEP could significantly increase transmitted resistance. However, if risk behavior remains stable, we find the concern is unfounded and PrEP interventions are likely to decrease transmitted resistance.

For the full study click here.

Treatment and PrEP could be on a ‘collision course’, warns resistance expert

via Aidsmap, by Gus Cairns

I’ve explained the importance of resistance at major think-tanks and people just don’t get it.

The world needs to prepare for a resurgence of HIV drug resistance if pre-exposure prophylaxis is widely adopted, a veteran HIV researcher warned the Microbicides 2010 Conference last week.

Dr John Mellors of the University of Pittsburgh has studied the dynamics of viral suppression and how drug resistance arises since the beginning of HIV therapy.

He admitted that, so far, “there are highly divergent opinions on whether PrEP will spread resistance." There is only one person in a PrEP trial with documented seroconversion while taking PrEP whose drug resistance was measured and this person turned out to have non-resistant ‘wild type’ virus.

However four PrEP trials are due to produce results by the end of this year – of drug users in Thailand, gay men in the USA, heterosexuals in Botswana and the multi-country iPrEX trial in gay men - and if one produces a significant result there will be pressure to roll out national programmes. Adopting these without careful monitoring could spread resistance to tenofovir and emtricitabine (FTC), currently the only drugs under study as PrEP.

Read the rest.

Microbicides, vaccines may need to repel HIV contact at mucosa

via Aidsmap News, by Keith Alcorn

Scientists have been faced with the question of how HIV actually gets underneath epithelial cells to infect other cells that are susceptible to HIV. "It's not the cells on top," Kaushic said. "It is the immune cells underneath that have all the receptors that HIV likes to latch on to and that allow the virus to replicate and establish infection. But it has to cross the epithelial barrier first!"

"This is a significant step forward in defining where prevention strategies, such as microbicides and vaccine, need to focus. Instead of trying to stop HIV from infecting the target cells underneath the epithelium, we need to think about ways to stop the virus from attaching to epithelial cells themselves," said Charu Kaushic.

Read the rest.

Poll finds majority in California support gay marriage; where do Times readers stand?

via Los Angeles Times, by Gerrick D. Kennedy

Less than two years after Californians approved a ban on gay marriage, a new poll found that more residents support same-sex unions than oppose them.

A poll from the Public Policy Institute of California released in March found respondents backing gay marriage 50% to 45%. And a Times/USC poll last November found a 51%-to-43% division on the issue.

The poll shows Democrats and liberals supporting same-sex marriage by large margins and Republicans and conservatives opposing it by equally lopsided margins. There is also a huge variation by age, with registered voters younger than 30 supporting same-sex marriage by roughly 3 to 1, while a majority of those 64 and older were opposed.

Here what others have to say about this and Read the rest.

Uganda's Anti-homosexuality Bill

via National Association of Social Workers of Uganda 

(who support this atrocious bill, by the way)

Statement On The Anti-Homosexuality Bill, 2009


 The object of the Bill is: "to establish a comprehensive consolidated legislation to protect the traditional family by prohibiting (1) any form of sexual relations between persons of the same sex; and (2) the promotion or recognition of such sexual relations in public institutions and other places through or with the support of any Government entity in Uganda or any non-governmental organization inside or outside the country".

Read the rest.

via Reverend Rowland Jide Macaulay

Leading African clergy, jurists and civil society groups call on Uganda to stop the Anti-Homosexuality Bill

Press Release:

March 31, 2009

The Anti-Homosexuality Bill provides for severe punishment, inclusive imprisonment, for those engaging in same sex relations, as well as for members of the public who fail to report such activities to the authorities. The original draft also provides for the death penalty and life imprisonment. The Bill has already gone through the first reading in Parliament and is now before the Legal and Parliamentary Affairs Committee.

“We are very concerned that it could become law within a few weeks or months”, said Adrian Jjuuko, Coordinator of Uganda's Civil Society Coalition on Human Rights and Constitutional Law.

Read the rest.

The Pope, Condoms and the Evolution of HIV

[Enjoy the additional Pope/condom images as light Friday entertainment from IRMA...]

From The Lancet Infectious Diseases, Volume 9, Issue 8, Pages 461 - 462, August 2009.

Samuel Ponce de Leon, et al.

The unjustifiable nature of the Vatican’s opposition to condoms in the face of the spread of HIV has been underlined by many.1 Moreover, the claims made by Pope Benedict XVI during his recent trip to Africa that the AIDS epidemic is a tragedy that “cannot be overcome through the distribution of condoms; on the contrary, they increase it”2 reveal, among other issues, a very poor under standing of the evolutionary future of HIV and the emergence of new strains.

The epidemic has led to the development of highly eff ective therapies based on new antiretroviral drugs, which unfortunately are not available to most African patients. These new treatments have been developed with little consideration of their evolutionary consequences, but HIV will not cease to evolve, as shown by the rapid resistance developed against the different combinations of drugs that are being used.3 Clinical data show that in some parts of Europe and the Americas one of every ten newly infected people has an HIV strain that is already resistant to one or more groups of antiretrovirals.4,5 Unfortunately, the list now includes primary infections in which multidrug-resistant HIV subtypes have been reported.6,7 The unavoidable conclusion is that sooner or later we will observe resistance to even the most efficient combinations of antiretrovirals, with all the clinical and epidemiological adverse consequences.8 Even if we are able to overcome the problems faced in the development of vaccines, they will not be 100% effective.

By contrast, condoms, by their very nature, stop infections but do not act as a selective agent. Pope Benedict XVI, together with physicians, policy makers, religious organisations, and, eventually, the population at large, should become fully aware of the obvious: by acting as a purely physical barrier, condoms not only have a key role in limiting the HIV pandemic, but also help to keep down the number of new strains.

The Vatican must understand that, in purely darwinian terms, HIV will never evolve resistance to condoms.

1 The Lancet. Condoms and the Vatican. Lancet 2008; 367: 1550.
2 The Lancet. Redemption for the Pope? Lancet 2009; 373: 1054.
3 Kantor R, Katzenstein DA, Efron B, et al. Impact of HIV-1 subtype and antiretroviral therapy on protease and reverse transcriptase genotype: results of a global collaboration. PLoS Med 2005; 24: e112.
4 Booth CL, Geretti AM. Prevalence and determinants of transmitted antiretroviral drug resistance in HIV-1 infection. J Antimicrobial Chemother 2007; 59: 1047–56.
5 Vercauteren J, Derdelinckx I, Sasse A, et al. Prevalence and epidemiology of HIV type 1 drug resistance among newly diagnosed therapy-naive patients in Belgium from 2003 to 2006. AIDS Res Hum Retroviruses 2008; 24: 355–62.
6 Blick G, Kagan RM, Coakley E, et al. The probable source of both the primary multidrug-resistant (MDR) HIV-1 strain found in a patient with rapid progression to AIDS and a second recombinant MDR strain found in a chronically HIV-1-infected patient. J Infect Dis 2007; 195: 1250–59.
7 Delaugerre C, Marcelin AG, Soulié C, et al. Transmission of multidrugresistant HIV-1: 5 years of immunological and virological survey. AIDS 2007; 21: 1365–67.
8 Hogg RS, Bangsberg DR, Lima VD, et al. Emergence of drug resistance is associated with an increased risk of death among patients fi rst starting HAART. Plos Med 2006; 3: 1570–78.

Testing Formula to Better Predict Treatment Failure/Drug Resistance

via Deborah Baron
IRMA Steering Committee Member

The Journal of the International AIDS Society published an article on a recent study testing a formula to better predict ARV treatment failure and possible drug resistance in the absence of viral load testing. According to a New York Times article on the study, "Scientists from Makerere University’s hospital in Kampala, Uganda, along with American and Belgian scientists, have developed a formula, based on close questioning of patients, for predicting which ones are most likely to have treatment failure."

The researches then compared their formula with the existing WHO guidelines, which relies on clinical and immunological criteria to identify treatment failure. They concluded that although "the WHO guidelines are used as a standard across many RLS [resource-limited setting, i]t is our view that this standard of care needs to be improved to reduce the late detection of viral failure and to minimize unnecessary switching of patients to second-line ART."

This formula could help provide useful insight to the ARV-based prevention research field, as it prepares for possible scenarios and challenges (if and when a product proves effective) around scaling up ARV-based prevention.

Check it out "Development and evaluation of a clinical algorithm to monitor patients on antiretrovirals in resource-limited settings using adherence, clinical and CD4 cell count criteria."

You can also link to the New York Times article on this study, "AIDS: Questions Help Find AIDS Patients Who Are Vulnerable to Drug Resistance"

SAVE THE DATE for IRMA's next Global Teleconference

SAVE THE DATE!


IRMA’s next Global Teleconference is a double feature, co-hosted with our friends at the Global Campaign for Microbicides

Wednesday, September 10, 2008


Kuala Lumpur – 2am (Thursday, Sept 11)
New Delhi – 11:30pm
Copenhagen – 8pm
Lagos – 7pm
New York City – 2pm
Chicago, Lima, Mexico City – 1pm
Seattle – 11am

Here is what is on that Double Feature:

Intro to Drug Resistance: Implications for ARV-based Prevention features Lori Heise of the Global Campaign for Microbicides

and

UCLA’s Leo Colemon will present Development, Recruitment, and Utilization of a Microbicide Research Registry.

Dial-in information is coming soon, via the IRMA listserv. In the meantime, please SAVE THE DATE and plan to participate in this global teleconference – part of an ongoing series of educational opportunities brought to you by IRMA.

Click here to sign up for the IRMA list.

Minutes from the most recent IRMA teleconference, “HIV-related Travel and Immigration,” held last week on August 19 in partnership with the Gay Men’s Health Crisis , are now online here.

Microbicides could prevent more infections in men than in women

Microbicides intended for vaginal use by women that contain non-nucleoside (NNRTI) antiretroviral drugs could end up preventing more infections in men than women, a mathematical model devised by biostatisticians from universities in Sydney, Montreal, Philadelphia and Los Angeles has found.

This paradoxical outcome might arise, the researchers say, because use of microbicides containing NNRTIs could result in a significant number of NNRTI-resistant HIV infections, especially if there is significant absorption into the body of women using them. Furthermore; because drug-resistant virus is often less fit than wild-type virus, female-to-male transmission would be less likely to occur. Men would also benefit more directly if the microbicide was ‘bi-directional’ and provided some protection for a man having sex with a women with HIV who was using it.

Microbicides containing antiretrovirals are being developed as a new generation of products following the failure of earlier types of microbicides. Antiretrovirals not in use for treatment of people with HIV are being investigated for their preventive potential when delivered within a gel for vaginal or rectal use. However, there are concerns that if the antiretroviral drug is absorbed into the body at low levels, the drug could give rise to resistance in people who are already infected with HIV. This is especially true for NNRTIs, where resistance to the currently licensed drugs in this class is quick to develop.

Read the rest of this article, by Gus Cairns, writing for Aidsmap.

Save the Dates - Upcoming IRMA Global Teleconferences

August 19, 11am eastern
HIV-related Travel and Immigration
(co-sponsored by Gay Men’s Health Crisis)
Speakers include:
Robert Bank, GMHC
Victoria Nielson, Immigration Equality
Eric Sawyer, UNAIDS
Vishal Trivedi, GMHC

Click here to read more about this call.

September 10, 2pm eastern
Intro to Drug Resistance: Implications for ARV-based Prevention
with Lori Heise of the Global Campaign for Microbicides
and after, UCLA’s Leo Colemon will present on their
Rectal Microbicide Participant Registry
as well as the study,
Barriers to Enrollment in a Registry for Microbicide Trials.

[More info on these calls will be sent out on the IRMA listserv. Sign up here.]

Check out the slides from previous IRMA teleconferences here.