The London SCG Commissioning intentions have been published and are available at this link below.

http://www.londonspecialisedcommissioning.nhs.uk/?assetId=705&assetGroupId=704

London Adult HIV Needs Assessment

The London SCG has published the Executive Summary of the Adult HIV Needs Assessment, This shows that HIV is one of the fastest growing chronic conditions in London.

http://www.londonspecialisedcommissioning.nhs.uk/?assetId=707&assetGroupId=704

Ensuring access to HIV care and treatment in London

With over 30,000 HIV positive patients receiving care in London, developing a plan to secure continued access to the best available treatment is critical.

http://www.londonspecialisedcommissioning.nhs.uk/?assetId=709&assetGroupId=704

Two doctors, who raised awareness for testing and treatment of HIV in Iran and who were the focus of a human rights campaign have now both been released. Doctor Arash Alaei and Doctor Kamiar Alaei were detained in June 2008 by Iranian authorities without cause and without charges or trial. [1]

The physicians, who are brothers, were held for over six months before being tried. On 31 December 2008, the brothers were tried as conspirators working with an “enemy government” to overthrow the government of Iran in a one-day, closed-door trial. They were also tried on unspecified other charges which neither they nor their lawyer were allowed to know. [1]

In the autumn of 2010, Kamiar Alaei was released from Evin Prison after serving two years of his three-year sentence. He moved to the US and worked for the release of his brother.

In August 2011, Arash Alaei was also released from Evin Prison after more than three years of a six year sentence. He rejoined his mother and other family members in Tehran and anticipates the resumption of his life-saving work, as well as reuniting with his brother, Kamiar, and sister in the US.

Physicians for Human Rights (PHR) is a campaigning organisation that raised the profile of Drs. Kamiar and Arash Alaei. We included this as a new item in October 2008 as their situation was also highlighted prominently at the IAS conference in Mexico City. [2]

Both doctors received the Jonathan Mann Award for Global Health and Human Rights in June 2011. [3]

A video of the brothers speaking about their detainment and release can be viewed online. [4]

References

1. Dr. Arash is Freed! PHR news feature. (29 August 2011).

http://physiciansforhumanrights.org/blog/dr-arash-is-freed.html

2. Free The Iranian HIV/AIDS Doctors! HTB October 2008.

http://i-base.info/htb/140

3. Alaeis Honored at Global Health Council Event. PHR news feature. (17 June 2011).

http://physiciansforhumanrights.org/blog/alaeis-honored-at-global-health-council-event.html

4. http://physiciansforhumanrights.org/library/multimedia/released-iranian-aids-doctors-share-story.html

It is with great pleasure, and considerable relief that we report that the New York State Supreme Court Justice Louis B. York granted summary judgment in favor of Richard Jefferys in a defamation lawsuit brought by an AIDS denialist named Celia Farber. [1] Jefferys was represented in the case by Joseph Evall of Gibson, Dunn & Crutcher.

The suit against Jefferys arose out of a May 12, 2008, comment he submitted via the now-defunct website for “Whistleblower Week,” conference. [2]

Jefferys was responding to an announcement that one of the conference sponsors was planning invite the AIDS denialists Celia Farber and Peter Duesberg to testify before a “tribunal” (including several Congresspeople), in the guise of whistleblowers.

In his comment, Jefferys asserted that Farber and Duesberg “are not whistleblowers, they are simply liars who for many years have used fraud to argue for Duesberg’s long-discredited theory that drug use and malnutrition – not HIV – cause AIDS.”

Jefferys wrote that he could provide “many, many examples, including their altering of quotes from the scientific literature, false representations of published papers, etc.” He stated that including Farber and Duesberg in this event “will, regrettably, discredit and demean your efforts to support the very real issues of recrimination against legitimate whistleblowers.”

Justice York found Farber to be a “limited purpose public figure,” which means that a defamation case can only be sustained if the alleged defamatory comments were malicious and knowingly false. Also, since HIV is a matter of public concern and debate, Jefferys would have to be shown to have been grossly negligent regarding the factual accuracy of his statements.

Justice York decided that Jefferys comments reflected his sincere and informed opinions and therefore met neither of these criteria. Justice York’s full opinion, which is available on the New York Courts website [3], provides a potted history of the AIDS denialism controversy and Celia Farber’s role within that controversy. But this decision is not a judicial verdict on AIDS denialism. Instead, it is a strong defense of freedom of speech on contested questions of public policy.

NY Law School Professor Arthur Leonard wrote: “In effect, Farber was contending that defamation law can be used to stifle criticism of a controversial position on a matter of great public importance.”

This report is edited from Arthur S. Leonard’s excellent detailed legal analysis of this case. [1]

References

1. New York Court Rejects Journalist’s Defamation Claim Against AIDS Activist. (12 November 2011).

http://newyorklawschool.typepad.com/leonardlink/2011/11/new-york-court-rejects-journalists-defamation-claim-against-aids-activist.html

2. Whistleblower Week In Washington (May 12-16 2008)

http://web.archive.org/web/20080517225306/http://www.w3conference.org/contact.htm

3. Justice York, Supreme Court, New York. (09 November 2011).

http://decisions.courts.state.ny.us/fcas/fcas_docs/2011NOV/3001063992009001SCIV.pdf

This is based the reduced infectivity associated with effective treatment together with high levels of infection control that are demanded of medical professionals that has resulted in much of Europe along with Australia and America having removed the restriction.

The article goes on to say that “sources in the medical profession say that even in Britain, where the ban is still in place, hospitals and dental surgeries have long operated a “don’t ask, don’t tell” policy with regard to practitioners who have HIV. They argue the policy is now clearly discriminatory as it can no longer be justified on public health grounds – despite the emotive nature of HIV.”

Apparently the decision to launch the review comes after the Department of Health’s Expert working group on AIDS and the UK Advisory Panel for Healthcare Workers Infected with Blood-borne Viruses both concluded that the risks could not justify the ban. They are believed to have told the Chief Medical Officer that the likelihood of any infection was as low as one case every 2,400 years.

Source: The Independent online. 24 November 2011.

http://www.independent.co.uk/life-style/health-and-families/health-news/ban-on-hivpositive-doctors-and-dentists-set-to-be-overturned-6267110.html

The following review provides an example of a unique and successful community-led treatment advocacy service.

Background

In the UK there is a high standard of health services available for HIV. The latest treatments, expert care and specialist support services are easily accessible. To compliment these services, i-Base produces publications targeting doctors, healthcare workers and HIV positive communities.

The i-Base Treatment Information Service, both phone- and web-based, is celebrating its 10th anniversary this year. The service offers high quality up to date information on HIV treatment and treatment-related issues. I-Base is the only organisations to provide an online HIV treatment-related question and answer service in the UK. This project is an example of a successful community-led advocacy project which aims to ensure positive people have access to the essential information they require to make informed decisions about their health.

All calls and enquires have anonymised data logged onto a database as part of the quality control for this service. This allows the project to review the important of different subjects and to track service use and response rates.

Use of service

From 2004 to June 2011, 1949 treatment calls have been taken and 3271 online questions answered. The demand for this service is growing exponentially. During 2010, 1036 web-based and 296 phoneline questions were answered. Table 1 below shows the numbers of questions answered broken down into 2-year periods including a projected estimate for 2011 based on 2010 figures.

Table 1: Calls and information requests 2004-201

The phoneline is free to call from within the UK but is not an international number and so is UK-focused only. The web-based Q and A service is available for people worldwide. 2010 has seen the most diverse use of this essential online service with only 31% of questions coming from people within the UK.

UK-based enquiries predominantly ask about treatment-related issues. The most common area where the positive community require more information is in related to side effects (23%) followed by starting and changing treatment (13% and 12% respectively).

Web-based questions cover both treatment, testing and transmission risk. This has led to the development of new online resources on testing and transmission to ensure the focus remains strongly on HIV treatment.

Monitoring the impact of the publications, phoneline and web-based services offered by i-Base is important if the services are to continue to meet the needs of the service users. Users are encouraged to provide feedback using a simple anonymous online survey.

Between July and December 2010, 108 feedback forms were received.

The results of this feedback are given as the percentage of service users providing this feedback for each point.

• 12% had called the phoneline
• 88% had asked a question either online or by e-mail
• 29% had read one or maore i-Base treatment guides
• 13% had read i-Base research reports (HTB etc)
• 48% were from outside the UK
• 6% were healthcare workers or treatment advocates
• 81% agreed with the statement: ‘I now understand more about HIV treatment’
• 82% agreed with the statement:  ‘I now feel more confident about dealing with HIV’

Evaluation and monitoring

Comments about the quality of i-Base information services given as part of the feedback form demonstrate its impact on the service users treatment decisions and the healthcare they receive. Examples of these comments and the impact of i-Base’s information services are as follows:

This is the second time I have used i-Base to ask a question relating to my treatment. Your website and available literature is very clear and your response to my specific question asked today was very prompt and helpful in helping me make a decision relating to participating in a study. Thank you very much.

As a care giver I want to be able to tell if my patient is receiving the right treatment…

My doctor has removed the excess drugs I was taking since I received the information you sent me. I feel lighter now that I have reduced the drugs from 5 to 3 ARVs. Once again thanks for your responses.  I will read the booklet you have referred to me.

Your suggestions and questions made it easy for me to have an intelligent conversation with the consultant. It also helped me to ask the right questions which in the end contribute do me making an informed decision that I left the clinic happy with.

Fantastic as always, i-Base! I wrote in with a question and it was answered the next morning. i-Base is a fantastic resource and the information provided is detailed yet always easy written in a way that is easy to understand. I don’t have much time with my doctor at the clinic and the team at i-Base have answered the questions that come up between visits and put my mind at rest. While it can be hard reading about some of the issues we face with HIV I feel it’s always better to understand and know what we may have to face in order to deal with it. Many thanks.’

Conclusion

HIV i-Base has been running for just over 10 years now and the range and type of services offered are unique in the UK.

I-Base is an example of a successful community-led intervention that is both empowering and informative.

In the current financial climate where resources are becoming more limited and the NHS more stretched in the time and quality of services they are able to offer each patient, there is an important role for community-led organisations such as i-Base to offer user-friendly treatment information and support to the positive community.

As we are a small organisation, this involves contributing to all aspects of the project, with an emphasis on the treatment information services (phoneline, email and web-based) and publications (HTB and treatment guides).

The successful candidate is expected to be familiar with the work we do (both nationally and internationally), keep up to date with scientific developments in HIV treatment and prevention and to be able to communicate these to others in many different formats.

We are looking for someone who is dynamic, treatment literate and self motivated. We are looking for someone who is happy to work independently and also as part of a team. There will be opportunities to develop new projects within our organisation.

The goal of our organisation is for excellent quality of care and equality of access for people with HIV.

We have an equal opportunities policy and we are particularly interested to hear from HIV-positive candidates.

This post can be part-time or full-time.

For more information:

http://i-base.info/about-us/volunteering-and-staff-vacancies/

A recent post covered a review by Beth Jamieson and Tammy Rickabaugh describing the parallel effects of HIV infection and aging on the pool of naïve T cells in humans. [1]

Three recent papers address different aspects of naïve T cell loss, including the first study to document a decrease in this population in people with chronic hepatitis C infection.

In PLoS One, Beth Jamieson’s group reports on a study of naïve CD4 T cell levels in younger (20-32 years) and older (39-58 years) individuals with untreated HIV infection, compared to age-matched HIV-negative controls. [2]

The researchers use a cell surface marker named CD31 to discriminate between naïve CD4 T cells that have recently been produced by the thymus (CD31+) and those that have proliferated in the circulation (CD31-). Consistent with previous studies, HIV infection had a strong effect on naïve CD4 T cell levels that was additive to that seen in aging; the absolute number of CD31+ naïve CD4 T cells in the younger individuals mirrored those measured in HIV-negative controls who were 17-28 years older. While both HIV infection and aging were associated with declines in CD31+ naïve CD4 T cell numbers, loss of CD31- naïve CD4 T cells was only observed HIV infection; in this case the effect was independent of aging as the absolute loss was similar in both the younger and older HIV-positive participants. In a separate longitudinal analysis of the effects of antiretroviral therapy, CD31+ naïve CD4 T cells achieved levels comparable to age-matched controls after two years of treatment. However, CD31- naïve CD4 T cell levels remained significantly reduced.

The researchers also evaluate telomere lengths in both naïve CD4 T cell subsets, finding them to be reduced both as a result of HIV infection and aging; as was seen for CD31+ naïve CD4 T cell numbers, the effects were additive. Jamieson and colleagues conclude by suggesting that their results likely explain why disease progression occurs more rapidly among HIV-positive individuals over the age of 50, because this older population already has reduced numbers of naïve CD4 T cells, making the impact of HIV infection more severe. They also note that incomplete recovery of naïve CD4 T cells may play a role in increasing the risk of aging-associated diseases in people with HIV.

One commonly cited causative mechanism of naïve T cell depletion in HIV is the persistent activation of these cells, which leads to their differentiation into memory cells. Another contributing factor is lymphoid tissue fibrosis (a type of scarring damage associated with immune activation & inflammation). Naïve T cells continually recirculate through lymphoid tissue and depend on signals received in that environment for their survival.

A recent study by Ming Zeng and colleagues delves into this link between lymphoid tissue fibrosis and naïve T cell loss in both SIV and HIV infection. [3]

The researchers find that fibroblastic reticular cells (FRC)–which form the pathways along which T cells travel in lymph nodes–are the major source of IL-7, a cytokine essential for naïve T cell survival. Fibrotic damage (measured by the accumulation of collagen) is shown to disrupt the FRC network and therefore impede the ability of T cells to access IL-7, causing an increase in T cell apoptosis. Both naïve CD4 and CD8 T cells are affected. Additional studies reveal that the loss of T cells in turn exacerbates the damage to FRCs by reducing the production of a cytokine called lymphotoxin-É¿, which is vital for maintaining FRC networks. The results suggest that there is a vicious cycle in which fibrosis damages FRCs, which causes T cell loss, which then further exacerbates FRC loss.

Continuing their investigative work, Zeng et al look for a source of collagen and find that production of the cytokine TGF-beta by regulatory T cells is increased in HIV, and TGF-beta induces collagen production by fibroblasts. In lab experiments, the antifibrotic drug pirfenidone blocks TGF-beta signaling and reduces collagen production, leading the researchers to conclude that this drug may deserve consideration as an adjunctive therapy for promoting immune reconstitution in HIV.

Lastly, a study published in the 1st March issue of the Journal of Infectious Diseases demonstrates that another persistent chronic infection, hepatitis C, can accelerate naïve CD4 T cell loss. The authors conclude that their findings provide an explanation for the reduced response to vaccinations observed in people with chronic HCV. [4]

Source: TAG basic science blog (17 Mar 2011)

http://tagbasicscienceproject.typepad.com

References:

1. Jamieson B and Rickabaugh T. A challenge for the future: aging and HIV infection. Immunol Res. 2010 Aug 24. [Epub ahead of print]
   http://www.springerlink.com/content/np150557h6u06316/
   See
   http://tagbasicscienceproject.typepad.com/tags_basic_science_vaccin/2010/09/losing-immunological-naivete.html
2. Rickabaugh TM et al. The Dual Impact of HIV-1 Infection and Aging on Naïve CD4 T-Cells: Additive and Distinct Patterns of Impairment. PLoS One. 2011 Jan 26;6(1):e16459.
   http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0016459
3. Zeng M et al. Cumulative mechanisms of lymphoid tissue fibrosis and T cell depletion in HIV-1 . J Clin Invest. doi:10.1172/JCI45157.
   http://www.jci.org/articles/view/45157
4. Yonkers NL et al. Reduced Naive CD4 T Cell Numbers and Impaired Induction of CD27 in Response to T Cell Receptor Stimulation Reflect a State of Immune Activation in Chronic Hepatitis C Virus Infection. J Infect Dis. 2011 Mar;203(5):635-45. Epub 2011 Jan 10.
   http://jid.oxfordjournals.org/content/203/5/635.abstract

On 28 February 2011, more than 30 scientists gathered for a one-day meeting prior to the 18th Conference on Retroviruses and Opportunistic Infections (CROI) to launch an international working group on HIV reservoirs and strategies to control them.

Under the auspices of the International AIDS Society, the scientists will guide the development of a global scientific strategy ‘Towards an HIV Cure’. The strategy aims at building a global consensus on the state of the HIV reservoirs field and defining scientific priorities that must be addressed by future research to tackle HIV persistency in patients undergoing antiretroviral therapy, the key hurdle impeding any alternative to long-term therapy. This global scientific strategy will help mobilise and focus resources to fund the most promising strategies towards either eradication or a functional cure, and stimulate international research collaborations.

The international scientific working group will be co-chaired by Professor Françoise Barré-Sinoussi, International AIDS Society (IAS) President-elect and 2008 Nobel Laureate for Medicine, and Professor Steve Deeks, University of California, San Francisco (UCSF) and Positive Health Program (AIDS Program) at San Francisco General Hospital. The working group will work closely with an advisory board composed of leading advocates and major research stakeholders in HIV cure, including representatives of people living with HIV, funders and clinicians from high prevalence settings. The advisory group will be co-chaired by Pr. Françoise Barré-Sinoussi and Dr. Jack Whitescarver, Director of the Office of AIDS Research at the National Institutes of Health.

This initiative comes on the back of the successful workshop ‘Towards a cure: HIV Reservoirs and strategies to Control Them’ held in conjunction with the 18th International AIDS Conference (AIDS 2010) in Vienna in July 2010. [1]

Source: IAS press release. Scientists unite to develop global scientific strategy towards an HIV cure. (28 February 2011).

Reference:

1. ‘Towards a cure’: HIV reservoirs and strategies to control them. 16–17 July 2010, Vienna. Powerpoint presentations and abstracts along with rapporteur summaries are posted online.
   http://www.iasociety.org/Default.aspx?pageId=349

Public online register gives access to information on clinical trials

The EU Clinical Trials Register (www.clinicaltrialsregister.eu) was launched on 23 March 2011 by the European Medicines Agency. The online register gives for the first time public access to information on interventional clinical trials for medicines authorised in the 27 EU Member States and Iceland, Liechtenstein and Norway. The database also allows the public to search for information on clinical trials authorised to be carried out outside the EU if these trials are part of a paediatric investigation plan.

The information contained in the EU Clinical Trials Register is extracted from EudraCT, the EU clinical trials database. It is provided by the sponsor of the clinical trial, and is a component of its application to a national medicines regulatory authority for authorisation to conduct a trial. The information from the sponsor is loaded into the EudraCT database by the national medicines regulatory authority. The authority adds to this information the authorisation of the clinical trial and the opinion from the relevant ethics committee. Information on third country trials that are listed in a Paediatric Investigation Plan (PIP) is provided by the PIP addressee directly, via the EMA, to the system.

Throughout the project the Agency worked together with stakeholders, including patients and healthcare professionals, to ensure that their needs were taken into account, to the extent possible at this stage, when designing the register.

The Agency will continue to work with stakeholders to improve the functioning of the EU Clinical Trials Register, in particular by enhancing the quality and completeness of data, and improving the search functionality. Plans for the future also include the publication of summaries of clinical trial results, on which draft guidance has already been published for consultation by the European Commission. Publication of trial results summaries will require a major upgrade to the existing system, the start of which will depend on finalisation of the guideline and availability of budget and resources.

The details in the clinical trial description include the:

• design of the trial;
• sponsor;
• investigational medicine (trade name or active substance identification);
• therapeutic areas;
• status (authorised, ongoing, complete).

Unfortunately the EU Clinical Trials Register website does not:

• provide information on the results of clinical trials;
• provide information on non-interventional clinical trials of medicines (observational studies on authorised medicines);
• for the period May 2004-March 2011 provide information on clinical trials where investigator sites are outside of the European Union and the European Economic Area. (However, information on clinical trials which are part of an agreed paediatric investigation plan (PIP) and were conducted outside the European Union and the European Economic Area will be published retroactively on the website by March 2012.);
• provide access to the authorisation document from the national medicine regulatory authority or the opinion document from the relevant ethics committee;
• provide information on clinical trials for surgical procedures, medical devices or psychotherapeutic procedures;
• manage the process for joining any clinical trial published on the website;
• provide navigation and web content in languages other than English.

comment

This development by the European Medicines Agency (EMA) on interventional clinical trials on medicines is an important first step in this resource for European patients.

Treatment advocacy is severely restricted when even a basic registry of ongoing studies is not mandatory. Transparency in ongoing research is an issue of public safety.

Source: EU press release. European clinical trials registry now online. (21 March 2011).

Links:

The EU clinical trials register is at:
https://www.clinicaltrialsregister.eu

Information on EudraPharm:
http://eudrapharm.eu/eudrapharm

Information on EudraCT
https://eudract.ema.europa.eu/

While homosexuality is already illegal in Uganda, this new law proposes to criminalise all homosexuality, making it punishable by a fine and life imprisonment. HIV-positive people, and people convicted a second time would be subject to the death penalty. The proposed bill also states that anyone knowing someone who is a gay man or lesbian would be mandated to report them to the police within 24 hours, or face imprisonment themselves.

David was one of three activists who sued the Ugandan newspaper Rolling Stone, not connected to the US magazine, after it published pictures and contact details of 100 gay men and women including David under the headline “Hang Them.”

David was a speaker at the International AIDS Conference held in Vienna last year. His courage at confronting bigotry and homophobia was immense.

A vigil was held at the Ugandan Consulate in Trafalgar Square, London at 11 am on Friday 28th January.

We send our deepest sympathy and condolences to Davids family and friends.

Sources and links:

Human Rights Watch
http://www.hrw.org/en/news/2011/01/27/uganda-promptly-investigate-killing-prominent-lgbt-activist

Justice for Gay Africans Society
http://jfga.org.uk/2011/01/26/david-kato-assassinated-would-the-lives-of-gay-african-people-ever-be-safer/

AIDS 2010 Vienna programme
http://pag.aids2010.org/session.aspx?s=97

Uganda law proposes death penalty for homosexuality: can international reaction and vulnerability of treatment access programmes help? HIV Treatment Bulletin, June 2010
http://i-base.info/htb/10436

The change was made on 19 April, a few days before the opening of a large international trade fair called Shanghai Expo, and follows similar policy changes in January by the US and South Korea.

The State Council reportedly posted a statement on its website that the government had passed amendments on 19 April, revising the Border Quarantine Law as well as China’s Law on Control of the Entry and Exit of Aliens. The changes were effective immediately. Restrictions for people with leprosy and sexually transmitted diseases were also removed.

Source: hivrestrictions.org

http://www.hivrestrictions.org

IAS statement in support of Chinese policy change:

http://www.iasociety.org/Default.aspx?pageId=408

A Malawian magistrate has sentenced Steven Monjeza and Tiwonge Chimbalanga to 14 years hard labour after convicting them of “indecent practices between males” and “unnatural offenses”. This is the maximum sentence under Malawian law. Monjeza and Chimbalanga were arrested after holding an engagement ceremony for their civil partnership. They were denied bail and imprisoned throughout their trial. Monjeza is male and Chimbalanga is a transgender woman.

The conviction and sentence have been condemned by AIDS and human rights groups across the world, as well as the United States and United Kingdom governments and the South African Human Rights Commission. Demonstrations against the conviction have been held at Malawian embassies in the UK, the US and South Africa, with more planned.

The Southern Africa Law Centre, Centre for Human Rights and Rehabilitation, Centre for the Development of People and the AIDS and Rights Alliance for Southern Africa are assisting Monjeza and Chimbalanga with their legal defence. The magistrate’s decision is being appealed.

The importance of this issue in the context of HIV prevention and treatment was highlighted by a press statement about the case, issued by the Global Fund for AIDS, TB and Malaria (GFATM). “The criminalisation of individuals based on their sexual orientation is not just a human rights issue – it also undermines investment in HIV and AIDS as it drives sexual behavior underground and creates an environment where HIV can more easily spread”, says Prof. Michel Kazatchkine, Executive Director of the Global Fund. “This ultimately affects the broader population, in addition to the devastating impact it has on communities of men who have sex with men”.

In southern Africa more than 50% of men who have sex with men also have sex with women. A recent study shows high levels of bisexual behavior in Malawi.

The linkage between proposed legislation in Uganda and actual judicial practice in Malawi – the links between MSM and HIV – are explained in an excellent article published last year in the Lancet by Adrian Smith and colleagues titled ‘Men who have sex with men and HIV/AIDS in sub-Saharan Africa’.

stop press

As this issue went to press we learned that the President of Malawi overturned the convictions and issued a pardon for Steven and Tiwonge.

This is an important outcome and achievement for these two people.

It needs to be followed with further progressive action, to enable similar abuses of  human right to be tackled systematically in order to reduce the stigma  faced by individuals highlighted by this case.

Magistrate Nyakwawa Usiwa-Usiwa’s judgment can be downloaded from:

http://www.southernafricalawcenter.org/download/6/23

A petition for Monjeza and Chimbalanga to be freed can be signed here:

http://www.petitiononline.com/M100518R/petition.html

Community Media Trust have produced a video about this:

http://www.youtube.com/watch?v=51h7TYKtBeA

Youtube video from Malawi that protests the case results:

http://www.youtube.com/watch?v=eyIUg2VyHDs&feature=related

Press statement from the Global Fund (21 May 2010):

http://www.theglobalfund.org/en/announcements/?an=an_100521b

Smith A et al. Men who have sex with men and HIV/AIDS in sub-Saharan Africa. The Lancet, Volume 374, Issue 9687, Pages 416 – 422, 1 August 2009. doi:10.1016/S0140-6736(09)61118-1

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61118-1/abstract

Growing publicity and concern over the proposals for Uganda to legislate even more severely against human rights on the grounds of sexuality have drawn widespread condemnation, but it currently remains unclear whether this will be sufficient to halt this shocking and depressing move. [1]

The proposed new laws, linking political opportunism, nationalism and religious extremism are particularly shocking for the devastating impact such discrimination has on the lives of gay men and women in Uganda and the impact this has on other African states.

It is also likely to contribute to reducing the effectiveness of HIV testing and treatment programmes on many levels. The discrimination faced by African men who have sex with men, and the link to HIV prevention was discussed in detail in an article last year in the Lancet which is available to view without subscription. [2] It is difficult to understand how this new legislation could help the currently fragile nature of international funding for treatment programmes. More depressingly, is the likely probability that the real impact on the lives of HIV-positive people is of no concern to those involved in the drive to impose the new legislation.

On the 14 October 2009, MP Bahati tabled the Anti-Homosexuality Bill in the Ugandan Parliament. The Bill is currently before the Legal and Parliamentary Affairs Committee.  The stated objective of the Bill is to establish a comprehensive law to supposedly protect the traditional family by prohibiting any form of sexual relations between persons of the same sex; and to penalise homosexual behavior, including a death penalty for “aggravated homosexuality”, to prohibit ratification of any international treaties, conventions, protocols, agreements and declarations which are contrary or inconsistent with the provisions of this Act, and to prohibit the licensing of organisations which promote homosexuality.   The Bill makes it an offence not to report homosexual practices to the authorities and even seeks to criminalise Ugandans who commit homosexual acts outside of Uganda.

Uganda’s Civil Society Coalition on Human Rights and Constitutional Law was established in October 2009 in response to the tabling of the notorious Anti-Homosexuality Bill in the Ugandan Parliament. The membership of the Coalition stands at 28 Ugandan civil society organisations.  Its initial campaign is to see the Bill dropped from the Parliament’s agenda. [4]

The Ugandans4Right.org website provides the most up-to-date information on the Bill, including the perspectives of the many Ugandans who are opposed to this draconian legislation. [4]

The story has been covered by mainstream media globally. In Uganda, BBC reporter John Simpson confronted the preacher Martin Ssempa saying “I have never heard so much hatred inside a church”.

The US Senate passed a motion condemning the action [5] and numerous online petitions and letters had been sent in protest.

A letter from Southern African HIV Clinicians Society to Uganda Parliament included the following comment on the impact this would have on HIV. [7] An excerpt from this letter is reprinted below:

• The measures proposed by the Bill will lead to the persecution of people who engage in same-sex relations.  There is a large amount of international research which demonstrates that when specific groups are subject to victimisation, stigma and discrimination, they are less able to access health care services, which is particularly detrimental to public health measures in the context of the HIV pandemic.
• By specifically targeting gay, lesbian and bisexual people who are living with HIV, the Bill will discourage such people from testing for HIV, knowing their status and accessing treatment. This will inevitably result in an increase in new HIV infections.
• The Bill seeks to criminalise “the promotion of homosexuality”, which includes funding organisations that work with lesbian, gay and bisexual issues, and the publication of material relating to these groups.  In effect, this will mean that civil society organisations will not be able to provide outreach and health information to the gay, lesbian and bisexual community in Uganda.  Preventing the dissemination of information on HIV prevention to a vulnerable group such as men who have sexual relations with other men will inevitably lead to a higher incidence of HIV in Ugandan society.
• If the Bill is passed into law, Uganda will necessarily have to withdraw from international human rights conventions, including the Universal Declaration of Human Rights; the International Covenant on Civil and Political Rights; the International Covenant on Economic, Social and Cultural Rights; the Convention on the Elimination of all Forms of Discrimination Against Women; the Convention on the Rights of the Child; and the African Charter on Human and Peoples’ Rights.  Since the protection of human rights is an important aspect of reducing stigma regarding HIV, any deterioration in the human rights situation in Uganda will seriously undermine the work that has already been done in promoting openness and preventing new HIV infections.

We therefore strongly believe that the Bill will have profoundly negative impact on Uganda’s efforts to combat HIV, and we call on all Members of Parliament who are committed to public health and human rights to ensure that this Bill is not passed into law in any form.

References:

1. Summary of Anti Homosexuality Bill, 2009.

http://www.ugandans4rights.org/issues.php

2. Anti Homosexuality Bill, 2009. Proposed bill in full (PDF).

http://www.ugandans4rights.org/downloads/09_10_14_Bill_No_2018_Anti_Homosexuality_Bill.pdf

3. Smith A et al. Men who have sex with men and HIV/AIDS in sub-Saharan Africa. The Lancet, Volume 374, Issue 9687, Pages 416 – 422, 1 August 2009. doi:10.1016/S0140-6736(09)61118-1

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61118-1/abstract

4. http://www.ugandans4rights.org/

5. US sentate resolution.

6. Online petition and further information on Internation Gay and Lesbian Human Rights Commission

http://www.iglhrc.org/cgi-bin/iowa/article/takeaction/resourcecenter/1088.html

7.  Letter from SA HIV Clinicians Society to Uganda Parliament

http://sahivsoc.org/index.php?option=com_docman&Itemid=59&task=doc_download&gid=65

On 2 November 2009, the US Department of Health and Human Services published final regulations that will remove HIV from its list of communicable diseases of public health significance and will remove the HIV test from the routine medical exam for lawful permanent resident applicants. The regulations will go into effect on 4 January 2010, following a routine implementation period.

This was announced during the presidential press briefing for the fourth reauthorisation of the Ryan White CARE Act, and included the following statement:

“Twenty-two years ago, in a decision rooted in fear rather than fact, the United States instituted a travel ban on entry into the country for people living with HIV/AIDS. Now, we talk about reducing the stigma of this disease – yet we’ve treated a visitor living with it as a threat. We lead the world when it comes to helping stem the AIDS pandemic – yet we are one of only a dozen countries that still bar people from HIV from entering our own country. If we want to be the global leader in combating HIV/AIDS, we need to act like it. And that’s why on Monday, my administration will publish a final rule that eliminates the travel ban effective just after the New Year. Congress and President Bush began this process last year, and they ought to be commended for it. We are finishing the job. It’s a step that will encourage people to get tested and get treatment, it’s a step that will keep families together, and it’s a step that will save lives.” (Applause)

Source: Obama B. Press Statement “Remarks by the President at signing of the Ryan White HIV/AIDS Treatment Extension Act of 2009. (30 October 2009).

http://www.whitehouse.gov/the-press-office/remarks-president-signing-ryan-white-hivaids-treatment-extension-act-2009

Related links:

Immigration resource with focus on HIV

http://immigrationequality.org/template.php?pageid=177

Report on Kaiser Network

http://globalhealth.kff.org/Daily-Reports/2009/November/02/GH-110209-HIV-Travel.aspx

IAS press release “IAS applauds White House announcement of repeal of the United States’ discriminatory and ineffective HIV entry and immigration ban”. (30 October 2009).

http://www.iasociety.org/Default.aspx?pageId=379

Global database on HIV travel restrictions

http://www.hivrestrictions.org

The following resource was developed by Birmingham Heartlands Hospital and is to be used with flow diagram ‘HIV and Influenza H1N1v’. This is an empirical protocol drawn up by individuals with some experience in the recent UK swine flu outbreak. Modifications have been made following a meeting at the HIV/ IAS conference 2009 in July. This is just one suggested clinical approach.

Please use and adapt this to your own clinic, if you would like to suggest improvements or share experiences please contact:

steve.taylor@heartofengland.nhs.uk

As they are produced, updated drafts will be posted online:

http://www.sexualhealthbirmingham.co.uk

Inquiry re HIV and swine flu: a suggested approach

• Does the patient have symptoms consistent with “typical” flu?

FLU DIAGNOSTIC CRITERIA

• An acute-onset illness with history of feeling feverish and confirmed temperature >38°C
• AND flu-like illness (two or more of the following symptoms: cough, sore throat, runny nose, limb/joint pain, headache)
• Significant diarrhea has also been described by several clinicians

If they fulfil the above criteria but have none of the conditions * or symptoms ** listed below, then advise the patient that they may be suffering from flu. Treatment can be obtained by calling the pandemic flu service line on 0800 1513 100 / 0800 1513 200 or visiting the website:

http://www.direct.gov.uk/pandemicflu

• They should be advised NOT to attend hospital unless they deteriorate, or if symptoms fail to improve within 48 hours of commencing flu antivirals, when they should be clinically assessed.
• Reassure them that it’s appears safe to take antiretrovirals (ART) with flu antivirals e.g. oseltamivir (Tamiflu).
• Although there is the potential for drug interactions between ART and osteltamivir we have taken the approach that potential benefits exceed the potential for side effects. Obviously this can be modified as new data emerges.
• The theoretical interactions with renally excreted drugs and osteltamivir have led us to recommend that if patients have significant renal impairment (ie eGFR <40 mL/min) inhaled Zanamivir can be considered as an alternative (see below).
• In pregnancy we have recommended inhaled Zanamivir (Relenza). However systemic treatment should not be withheld if the clinical condition warrants treatment. (Deaths have occurred in pregnant women who maybe at greater risk of severe infection).
• Reassure the patient that most people with uncomplicated flu will be significantly better within 48hours.
• Alternatively persons with severe symptoms that are not classically flu-like should be assessed and have flu swabs performed since a negative test can be very informative.

If the patient meets the flu diagnostic criteria above AND has any of the following conditions* then they need to be assessed by the ID/HIV/GU registrar on call for the day ______________________________ : [INSERT APPROPRIATE NUMBER]

• Conditions requiring assessment by a registrar:
  • Pregnancy (any trimester)
  • Asthma and other chronic lung disease
  • Morbid obesity
  • Significant immune suppression

Note: We suggest assessing patients with CD4 counts <200 or CD4% <15% with symptoms as they may have an alternative non-flu diagnosis. These cases should be discussed with a senior member of the HIV team or the ID /HIV/GUM registrar on call.

If the patient meets the flu diagnostic criteria above, but also has any of the following symptoms** they should be assessed by the ID/HIV/GUM registrar on call for the day immediately.

** Additional symptoms requiring immediate assessment

• Significant breathlessness or patient is unable to complete sentences
• Hypoxia <94% on air
• Unable to tolerate oral fluids or has significant vomiting
• Confusion
• Hypotension systolic BP <90
• If the patient has already received flu antivirals and is not showing signs of improvement after 48 hours or is feeling worse.

Flow diagram A: HIV and Influenza H1N1v (Birminham Heartlands Hospital)

HIV patients may come into contact with hospital services in various ways. Flow diagram A outlines a suggested protocol for 2 of a common scenarios: telephone contact to members of the HIV team or unplanned presentation to HIV/ID/GUM outpatient clinics.

Treatment

• Flu antivirals should be obtained by the patients calling the pandemic flu service line on 0800 1513 100 / 0800 1513 200 or visiting the website: http:www/direct.gov.uk/pandemicflu
• Oseltamivir (Tamiflu) is the currently recommended first-line flu antiviral for most HIV patients and it should be commenced immediately. The dose is 75 mg bd for 5 days.
• In patients with significant renal impairment (eGFR <40 ml/min) or pregnant women we would consider using inhaled zanamivir (Relenza) as an alternative. However, If symptoms are significant, discussion should be sought with senior member of the HIV team with regards to the use of osteltamivir.
• Inhaled zanamivir: Two 5mg blisters are to be inhaled (using the ‘Diskhaler’) twice a day for at least five days (equivalent to 10mg twice a day for five days). The patient needs to be capable of using disk haler for administration.
• If intolerant of zanamivir, oseltamivir may be used with caution +/- dose modification. For further information contact ID/ HIV/GU registrar on call [INSERT NUMBER AND BLEEP].

Prophylactic/post exposure treatment

• For HIV positive patients with CD4 > 200 or >15% we would not routinely recommend prophylaxis but instead suggest standard treatment IF the patients develops symptoms and meets the flu criteria above.
• For HIV positive patients with CD4 <200 or <14% prophylaxis may be considered in cases of significant exposure. However to date there is no data to suggest that these individuals are at increased risk of severe disease.
• Please remember in patients with CD4 counts <200 or <14% other opportunistic infections may present with flu like symptoms and patients should have diagnostic swabs to aid diagnosis and be discussed with a senior HIV doctor or ID/HIV/GUM SPR on call.
• For a usable definition we have classified significant exposure as sitting <1 metre from an infected individual for >1 hr.
• The oseltamivir (Tamiflu) dose when used as prophylaxisis 75 mg od for 10 days.
• Inhaled zanamivir: Two 5mg blisters are to be inhaled (using the ‘Diskhaler’) once a day for at least ten days (equivalent to 10mg twice a day for five days) The patient needs to be capable of using diskhaler administration.

Diagnostic swabs for influenza

• Although swabbing is now not routinely being performed we would advocate taking swabs in individuals infected with HIV as knowledge of negative results may be useful. The patient does not have to attend hospital for this and can be organised via GP or flu treatment centres.

Flow diagram B (Chelsea and Westminster Hospital, London)

The second example flow diagram was produced for managing patients at the Chelsea and Westminster Hospital in London.

A caution with this option is that a patient with a life-threatening condition who thought they had flu could end up going down the left-hand ‘no further action’ route. The standard government advice on risk factors (eg. chronic heart, renal, liver, neurological disease), is non-evidence-based and may not be relevant in this (or possibly any) flu outbreak. It also does not address exposure

Does the patient have influenza-like illness symptoms?

• Temp >38°C or history of fever AND two or more of:
• cough, sore throat, runny nose, limb or joint pain, diarrhoea, headache

NO → Assess the patient’s symptoms and triage as you would for any other patient telephone enquiry.

YES → Do they have any of the following underlying conditions?

• Advanced HIV disease with CD4 <200 (or <14%)
• Pregnancy
• Asthma
• Chronic lung disease, chronic heart disease, chronic renal disease, chronic liver disease or chronic neurological disease
• Malignancy currently being treated, or having been recently treated with chemotherapy
• Other immunosuppressing conditions
• Any condition for which the patient is receiving immunosuppressing medication

NO → Do they have any of the following symptoms?

• Significant breathlessness or are unable to complete sentences
• Increased rate of breathing
• Unable to tolerate oral fluids of has significant vomiting
• Confusion, striking agitations, visual disturbance, limb weakness or seizures
• Irregular heart beat/palpitations or chest pain
• Blood-stained sputum

NO → Advise the patient that they may be suffering from flu and that they need to call their GP or the National Pandemic Flu Service on 0800 1 513 513 for further assessment. They should be advised not to attend hospital unless they deteriorate or there is no improvement.

YES → Must be seen IMMEDIATELY in their nearest A&E

YES → Do they have any of the following symptoms?

• Significant breathlessness or are unable to complete sentences
• Increased rate of breathing
• Unable to tolerate oral fluids of has significant vomiting
• Confusion, striking agitations, visual disturbance, limb weakness or seizures
• Irregular heart beat/palpitations or chest pain
• Blood-stained sputum

NO → Must be assessed in Daycare or A&E if out of hours.

YES → Must be seen IMMEDIATELY in their nearest A&E

Q. Are HIV-positive people more at risk of catching swine-flu?
A. No. Generally, as with other strains of flu, having HIV does not increase your risk of catching swine flu.

Q. Are HIV-positive people at risk of becoming more ill from swine flu?
A. Not generally. It may be more serious if you have a low CD4 count (less than 200 cells/mm³). This is mainly because symptoms of other serious infections could be mistaken for flu. If you have flu symptoms and either a low CD4 count, other health complications or are pregnant, please call your HIV clinic.

Q. How is swine flu different from regular seasonal flu?
A. Because this is a new strain of flu virus, no-one is currently immune. Researchers are already working to produce a vaccine, and this may, or may not, be ready in time for the next flu season.

Q. How is swine flu spread?
A. Swine flu is spread by person-to-person contact, just like regular flu – specifically through not covering your mouth when sneezing and not washing your hands.
Catch-it, Bin-it, Kill-it. (www.nhs.uk)

Q. Will flu meds work in people who are HIV-positive?
A. Antiviral medications used to treat flu (for example, oseltamivir (Tamiflu) and zanamivir (Relenza ) will work in HIV-positive people. The main reson to take them is to reduce how infectious you are.

Q. Will flu treatments interact with my HIV drugs?
A. There is a potential for interactions between Tamiflu, boosted PIs and some nukes (3TC, FTC and tenofovir) but the benefits outweigh this small risk. Your pharmacist will advise you on this. *

Q. When does seasonal flu occur?
A. The risk period for flu, including swine flu, is during the autumn and winter, especially from September to December.

Q. What is the risk that this years’ flu will be swine flu and be more severe?
A. This is difficult to predict. Hopefully, there is only a small chance of such a serious outbreak this year.

Q. Should I have the flu vaccine?
A. HIV-positive people are routinely recommended to have the seasonal flu vaccine. You need to be registered with a GP to get this and any new vaccinations. Your clinic can help with this or see: http://www.nhs.uk/servicedirectories/Pages/serviceSearch.aspx

Q. Where can I get more information?
A. The NHS website will provide updates. Your doctor and clinic will have specific information too.

See also:

i-Base:
0808 800 6013
(Mon, Tues, Wed 12- 4pm).
www.i-Base.info

NHS direct:
0845 46 47 (24 hours)
www.nhsdirect.nhs.uk

THT direct:
0845 12 21 200
(Mon-Fri 10am- 10pm; Sat/Sun 12noon-6pm)
www.tht.org.uk

Please also see information on NHS direct web site:
www.nhs.uk/AlertsEmergencies/Pages/Pandemicflualert.aspx

* Ref: A technical summary is on the Liverpool interactions website document:
http://www.hiv-druginteractions.org/new/Uploaded_Attachment/76_Flu_Chart_update.pdf 440 Kb

Edwin J Bernard, web blog

The 25 year jail sentence for a gay man in Iowa earlier this week for not disclosing his HIV status prior to one-time sex with a man he met online, reaches new lows in the history of criminalisation. [1] This is a potential human rights violation almost on par with Willie Campbell’s 35 year prison sentence for spitting. [2]

The ‘Waterloo and Cedar Falls Courier’ reports that Judge Bradley Harris sentenced 34 year-old Nick Clayton Rhoades to 25 years in prison, the maximum punishment under Iowa’s draconian (and mistitled) “criminal HIV transmission” laws, following a guilty plea. [3, 4]

There was no transmission: the male complainant has not tested HIV-positive, and it is now almost a year since the encounter. This subtlety seems lost on the headline writer, who erroneously states: ‘ Plainfield man gets 25 years for “transmitting” HIV’.

Not only was there no sentence reduction due to Mr Rhoades’ plea (after all, he saved the court a lot of time and money; and let’s face it, it was one person’s word against the other, which could have gone either way with a jury), but Judge Harris additionally placed Mr Rhoades on lifetime parole and ordered him to pay court costs and restitution.

In addition, he ordered that must Mr Rhoades must: not contact the complainant for five years, register as a sex offender and undergo a sex offender treatment programme.

Rhoades, who was diagnosed with HIV in 1998, was arrested in September. Living with the virus is like “carrying a concealed weapon,” he told the court, saying he felt guilty for exposing an unknowing individual to the disease.

“I always wanted to be part of the solution, and not part of the problem,” said Rhoades, who had previously participated in AIDS education efforts. “Clearly, I’ve fallen short in this case.”

Mr Rhoades sounds like a genuinely remorseful man. He believes that he should have disclosed his status, and didn’t. Even if you agree with HIV disclosure laws in general – notwithstanding arguments supporting the concept of shared responsibility of both parties under these circumstances, or the unreliability of disclosure as a way of protecting yourself from sexually transmitted infections – there really is absolutely no justification for this outrageously long prison sentence.

To put this into perspective. A year ago I reported on a 12 year HIV exposure sentence in Arkansas (where the maximum penalty is 30 years) for a man who did not disclose to his girlfriend. [5] At the time, it was the longest sentence I’d heard of for a single complainant. This is a single act!

Notwithstanding Johnson Aziga’s likely life sentence after recently being found guilty of murder, [6] the previous longest-ever sentence in Canada was 18 years, and that was for Carl Leone, with 15 complainants, including five who tested positive. [7]
The longest sentence in Europe has been for Christer Aggett, sentenced to 14 years in prison in Sweden, with a dozen complainants, two of whom tested positive, and half of whom were under 15. [8]

In 2006, the Iowa Supreme Court upheld the law after Adam Musser, 25, appealed his four convictions – and 25-year-prison sentences – for having unprotected sex with four different women in 2002 and not telling them he was HIV-positive. [9]
And yet, in 2007, a woman who also pleaded guilty after not disclosing her status to a single complainant during a three month relationship, had her 25 year prison sentence suspended and received four years probation. [10]

Since Judge Harris has also ruled that he can adjust the sentence any time within the next 12 months (and there is already a precedent to suspend sentencing), I suggest that anyone who feels as outraged as I do, contact either Judge Harris, or Mary Stegmeir (mary.stegmeir@ wcfcourier.com), the journalist who reported the case.

Source: Edwin J Bernard web blog (3 May 2009)
http://criminalhivtransmission.blogspot.com/2009/05/iowa-gay-man-gets-25-years-for-one-time.html

References
1. http://criminalhivtransmission.blogspot.com/2008/10/us-iowa-man-arrested-for-unprotected.html
2. http://criminalhivtransmission.blogspot.com/2008/05/us-dallas-man-gets-35-years-for.html
3. http://www.wcfcourier.com/articles/2009/05/02/news/breaking_news/doc49fb4f4b33dc0897631615.txt
4. http://www.gnpplus.net/criminalisation/index.php?option=com_content&task=view&id=315&Itemid=45
5. http://criminalhivtransmission.blogspot.com/2008/05/33-year-old-arkansas-man-who-pleaded.html
6. http://criminalhivtransmission.blogspot.com/2009/04/canada-aziga-sentencing-delayed-pending.html
7. http://criminalhivtransmission.blogspot.com/2008/04/canada-carl-leone-sentenced-to-18-years.html
8. http://criminalhivtransmission.blogspot.com/2008/02/sweden-british-man-sentenced-to-14.html
9. http://www.radioiowa.com/gestalt/go.cfm?objectid=552D3D13-496F-41E0-A5D8227A71CDE11B
10. http://criminalhivtransmission.blogspot.com/2007/11/iowa-woman-receives-probation-after.html

In July 2008, President Bush signed a law authorising the Department of Health and Human Services to lift the decades-long ban on foreigners living with HIV entering the United States. The U.S. is one of only 14 countries* in the world that bar entry to persons with HIV, a fact that has drawn broad condemnation from both domestic and international human rights organisations. Yet the ban still has not yet been stricken from DHHS regulations; instead, the Department of Homeland Security put into place a series of measures designed to “streamline” the process for entry into the US for people living with HIV. However, this process is an ill-conceived bureaucratic tangle with such onerous requirements that it is tantamount to a complete ban on people living with HIV coming into the United States.

“This new incident proves that AIDS stigma is alive and well in the United States and actively being promulgated by the United States government,” said Housing Works President and CEO Charles King. “President Obama says that he wants to repair America’s damaged relationships with foreign countries. Let him prove it by taking immediate action to ensure that the DHHS gets this hateful regulation off its books.”

The 60 Canadians had planned to attend the North American Housing and HIV/AIDS Research Summit in Washington, D.C. from June 2 to June 5. The OHTN and NAHC are cosponsors of that event.

In March, DHHS officials indicated that granting a “designated event HIV waiver” for the Housing Summit was underway. Such waivers are designed to allow people living with HIV to attend conferences in the U.S. On Friday, May 22, 11 days before the summit start date, the Ottawa Embassy informed the OHTN that each of the 60 people in its delegation to the Washington, D.C. AIDS Housing Summit would have to comply with the new, severely onerous visa process.

The visa process requires, among other things, a face-to-face interview; a photo; a $131 money order from a specific Canadian bank; an agreement not to extend the visit for any reason; completion of an intrusive and humiliating health form, and a pledge that the applicant has adequate health coverage – something that many US citizens living with HIV/AIDS are still denied.

To add insult to injury, because the OHTN was informed of the new requirements on Friday, May 22, HIV-positive Canadians could not even attempt to meet those requirements until Monday, May 25, barely one week from the June 2 start date of the conference – and to do so, they would have to travel from all over Canada to a specific Ottawa US consulate.

“Not only are these requirements an affront to people living with HIV in Canada, they were impossible to meet. There was no way to physically get people to the Ottawa Embassy on such short notice,” said Dr. Sean B. Rourke, Scientific and Executive Director of OHTN. “Furthermore, requiring people to give their name, a photo and confidential health information to the U.S. government is a violation of their privacy and inconsistent with our commitment to protect personal health information. It shows a lack of sensitivity to the very real stigma and discrimination that people living with HIV/AIDS face every day of their lives.”

*The other countries that ban visits by people living with the HIV besides the United States of America are Brunei, Egypt, Iraq, Yemen, Malaysia, Oman, Qatar, Singapore, Sudan, South Korea, Tunisia, Turks & Caicos Islands and the United Arab Emirates

Source: Housing Works Press Release. (28 May 2009).
http://www.housingworks.org/news-press/

The successful applicant must be self motivated and able to work in a very dynamic and challenging environment. The editor will be responsible for establishing and maintaining the Southern African HIV Nursing Magazine. This will include:

• Responsibility for acquiring, reviewing and editing all articles published in this magazine.
• Maintaining the magazines standards and editorial policies in line with international standards.

Qualifications

Degree level education preferably in nursing or another health-care related field, with a post-graduate degree in journalism or other relevant discipline, or equivalent experience with progress towards such a preferred qualification.

Experience

• 10 years practical work experience
• Experience and/or knowledgeable of the HIV/AIDS sector
• Experience with an NGO, implementation-focused donor or development organisation
• Experience and / or knowledge in the academic publishing field
• Proven track record as a published author in academic publications

Remuneration

Remuneration is dependent on skills, experience and qualifications.

To apply

To apply, please submit a detailed CV, including contact details of three referees, a letter of motivation and a copy of an original (and unedited) writing sample to:

The General Manager, The Southern African HIV Clinicians Society, by email to:
fatimas@sahivsoc.org

Closing date 28 August 2009

Only short-listed candidates will be contacted

For more information about the Society visit
http://www.sahivsoc.org

The groups said that respect for human rights and HIV prevention should be at the heart of the policy, but that critical elements had been stripped from the final declaration. They called on member governments to refuse to support the declaration, which is being considered at the high-level segment of the Commission on Narcotic Drugs (CND) this week in Vienna.

“Government delegations could have used this process to take stock of what has failed in the last decade in drug-control efforts, and to craft a new international drug policy that reflects current realities and challenges,” said Prof. Gerry Stimson, executive director of the International Harm Reduction Association. “Instead, they produced a declaration that is not only weak – it actually undermines fundamental health and human rights obligations.”

What is at issue is a series of measures known collectively as “harm reduction services,” which have been endorsed by UN health and drug-control agencies, including the UN Office on Drugs and Crime, UNAIDS and the World Health Organization. These measures include needle and syringe exchange and medication-assisted therapy (for example, with methadone), both inside and outside prisons, as essential to address HIV among people who use drugs. The groups noted that a wealth of evidence proves harm reduction is essential to HIV prevention for people who use drugs. The action was taken against the direct advice of UNAIDS, the Global Fund to fight AIDS, Tuberculosis and Malaria, and the UN special rapporteurs on health and on torture.

Up to 30 percent of all HIV infections outside of sub-Saharan Africa occur via unsafe injecting drug use. The groups said there is clear evidence that harm reduction interventions can halt or even reverse HIV epidemics among people who inject drugs.

“This political declaration fails public health,” said Craig McClure, executive director of the International AIDS Society. “Coming less than 12 months after UN member states convened a high level meeting in New York to restate the international commitment to fight HIV, the denial of any reference in the declaration to life-saving harm reduction programs is unacceptable and unconscionable.”

The political declaration also fails human rights. In country after country around the world, abusive law enforcement practices conducted under the banner of the ‘war on drugs’ result in extensive, and often horrific, human rights violations. In addition, overly restrictive interpretations of the international drug-control treaties at national level result in the denial of access to essential pain medications to tens of millions of people worldwide.

Both of these issues were raised by the UN special rapporteur on health and the UN special rapporteur on torture, who wrote to the CND to urge explicit support for human rights within the political declaration. All member states of the UN have ratified at least one of the core UN human rights treaties, and the UN General Assembly has consistently stated that drug enforcement must be carried out in a manner consistent with respect for human rights.
“Given the widespread human rights abuses around the world directly resulting from drug enforcement, human rights must be placed at the heart of UN drug policy,” said Joseph Amon, director of Human Rights Watch’s health and human rights division. “But the political declaration makes scant reference to the legal obligations of member states under international human rights treaties, nor does it insist on respect for human rights in drug policy.”

The groups called on member states not to lend their names to a political declaration that does not sufficiently prioritize the centrality of harm reduction and human rights within the global response to drugs, and join the call from other civil society organizations for further efforts across the UN system to find a more effective, coherent, and relevant response to drugs.

Source: Joint HRW, IAS and IHRA press release ‘New 10-Year Pllan Omits Critical l Protections on HIV and Human Rights’. (11 March 2099)

The UN Political Declaration on Drugs:
http://www.unodc.org/unodc/en/press/releases/2009-12.03.html

January 2009 overview by IHRA and HRW “International l Support for Harm Reduction”:
http://www.hrw.org/en/news/2009/01/19/international-support-harm-reduction

Human Rights Watch’s work on drug pollicy:
http://www.hrw.org/en/news/2009/03/09/un-drug-summit-undo-decade-neglect

Matthias Rath is a vitamin salesman and charlatan who claimed that his products reverse the course of AIDS and that ARVs are toxic and unnecessary. He also claims his products treat diabetes, heart disease, cancer and many other ailments. He started his activities in South Africa in 2004 and received extensive support from state officials and the Minister of Health for his unlawful and deadly activities.

South African government takes action against Matthias Rath

On 13 June 2008, the Cape High Court ordered the Minister of Health (then Manto Tshabalala-Msimang) to take steps to prevent Rath and his agents from conducting unauthorised clinical trials and from publishing advertisements about the medicinal effects of Rath’s product VitaCell. The state was also ordered to investigate these unlawful actions by Rath.

The court case arose because of the state’s failure to investigate or stop Rath’s unlawful activities. The court also interdicted Rath and several of his agents from continuing the above activities. The applicants in the case were TAC and the South African Medical Association (SAMA).

Last year, TAC member Sylvia Fynn discovered that the South African National Civics Organisation (SANCO) was continuing to distribute Rath’s medicines from a facility in Durban. SANCO was also discouraging patients from taking ARVs. Fynn photographed a bin where patients had thrown away their scientifically proven medicines, apparently with the intention of using Rath’s medicines. The Southern African HIV Clinicians Society (HIVSOC) also collected information on Rath’s activities in Durban. Both the TAC and HIVSOC sent our information to the Department of Health. We have since communicated extensively with the Department. We have been impressed by the co-operation we have received from Department officials.

We are pleased to announce that the Department is attempting to implement the court order. We have received a letter, signed on 27 February, from Dr J. Gouws of the Department’s Law Inspectorate stating: “I thank you for the information shared … I wish to inform you that following the order of the Cape High Court … the Department has embarked on investigation against Matthias Rath and Dr Rath Health Foundation Africa to ensure compliance with the said Court Order”.

The TAC welcomes and thanks the commitment and co-operation of the Department of Health over the last few months in this investigation. We also thank the Southern African HIV Clinicians Society for collecting evidence of continued infringements of the court order. Bringing charlatanism under control following the era of state-supported AIDS denialism is an immense challenge, but by taking action against Rath the Department of Health is sending the right message to other charlatans. This is an important first step.

We hope that a warrant of arrest will soon be issued for Rath. While it is unlikely it will ever be executed because Rath has left South Africa, it will be important symbolically to close this tragic affair, which has directly cost the lives of several of Rath’s patients and indirectly cost the lives of countless others who were confused by the false messages of Rath, supported by former Minister of Health Tshabalala-Msimang.

Rath appeal l against Cape High Court judgment lapses

Following the Cape High Court verdict, Rath lodged an appeal. TAC in turn counter-appealed (because we believe some aspects of the judgment could be stronger), and applied for an interim execution order. Rath’s leave to appeal was granted, but so was TAC’s leave to counter-appeal and our request for an interim execution order. Simply put, this means that the Cape High Court order against Rath would stand until the appeal was heard.

Matthias Rath has however failed to file further court papers and is now out of time. The appeal process is therefore over and this court case is now complete. The Cape High Court order stands unchallenged. Our lawyers have
therefore begun the process of redeeming their considerable costs from Rath.

TAC, SAMA and many other organisations have campaigned for Rath’s unlawful activities to be stopped. To TAC’s knowledge, Rath’s enterprises no longer have a significant presence in South Africa and the vast majority of Rath’s unlawful activities in the country have ended.

Source: TAC press statement

Further information:
http://www.tac.org.za/community/rath
http://www.tac.org.za/community/RathWrongs

The numerous articles and obituaries linked below hint at the impact from over 20 years work to extend and improve lives of HIV-positive people. He was as concerned with individual empowerment and care as he was changing policy on a national level.

He played a major role in changing the FDA drug approval process: shortening approval time for life-saving drugs and establishing the right for patients to choose to access treatment prior to approval through expanded access programmes.

His experience from the earliest pre-treatment years, first drug trials and later understanding of HAART, through to recent focus on drug costs and pricing, ensured he was one of the most informed and intelligent people working in HIV and he will be greatly missed.

Related links:

Project Inform
http://www.projectinform.org/martindelaney.shtml

NIAID
http://www3.niaid.nih.gov/about/directors/news/Martin_Delaney.htm

NIAID Honors AIDS Activist Martin Delaney
http://www3.niaid.nih.gov/news/newsreleases/2009/mdelaney.htm
http://www.youtube.com/watch?v=Ud51h76u3cc

Treatment Action Group
http://www.treatmentactiongroup.org/base.aspx?id=2802

POZ magazine
http://www.poz.com/articles/hiv_martin_delaney_401_16017.shtml

New York Times
http://www.nytimes.com/2009/01/27/us/27delaney.html?_r=1&partner=rss&emc=rss

Community memorial site
http://www.martydelaney.com

Several years ago, allegations from a fringe group of HIV denialists who claiming that foster children in New York were used as guinea pigs for adult HIV drug trials, gained media publicity when used as a basis for a BBC documentary. It is important that these have been quashed following a lengthy investigation, detailed in a recent article in the New York Times. [1]

Complaints to the BBC after the documentary was aired in 2004, also resulted in a lengthy apology and retraction recognising the inappropriate balance used in their programme. [2]

An independently commissioned investigation determined that city officials had acted in good faith and in the interests of the children, many of whom were seriously ill.

The report, from the Vera Institute of Justice, an independent nonprofit group, is now available online [3]. It also found that foster children were not removed from their families because a parent had refused to consent to a child’s treatment, and that researchers did not specifically select foster children for enrollment in the trials. While the foster children were overwhelmingly black and Hispanic, as some critics, this mirrored the demographics of children with HIV infection in the city at the time.

COMMENT

This was probably one of the most inappropriate and inflammatory HIV-realted stories to picked up by mainstream media who themselves failed to appropriately research the real issues: that children are generally denied access to potentially life-saving pipeline compounds until after they have been approved for adult care.

References
1. Foderaro L. Study refutes claims on AIDS drug trials, New York Times (27 January 2009).
http://www.nytimes.com/2009/01/28/nyregion/28foster.html?_r=1
2. BBC Admits that “Guinea Pig Kids” is Misleading, Erroneous: Apologises for HIV Denialist Bias and False Allegations about NYC AIDS Drug Trials
http://www.aidstruth.org/BBC-Apologizes-for-HIV-Denialist-Bias.php
Link to BBC letter
http://www.aidstruth.org/Complete-BBC-complaint.pdf
3. Ross T et al. The Experiences of New York City Foster Children in HIV/AIDS Clinical Trials. Available online:
http://www.vera.org/cyj/hivtrials-pubs.html

The US HIV travel ban was consistently opposed by HIV activists and the decision taken by the IAS to refuse to hold meetings in the US was widely supported.

The 2012 meeting, held from 22-27 July, is expected to attract more than 25,000 delegates from nearly 200 countries, including more than 2,500 journalists.

Source: Press release, International AIDS Society. The IAS announces Washington, DC, as site of the 19th International AIDS Conference in July 2012: removal of entry restrictions on People Living with HIV by the U.S. allows for return of conference after 22-year absence. (30 Nov 2009).

The IAS maintains a detailed global database on HIV-related travel restrictions:

http://www.hivtravel.org

Changes include:

• a change in name (from EMEA to EMA) and website address
• integration of human pre- and post-authorisation activities into one unit
• the creation of a new unit for patient health
• a dedicated group for the management of product data

Established in 1995, this is only the second time there has been a major re-organisation of the Agency’s services.

A new public website for the Agency is nearing the end of development and will be launched in 2010. With the current website being visited more than 700,000 times each month, the new site is being designed with the needs of the public in mind, offering improved navigation and search functionality, providing better access to information on public-health issues.

Source: EMA press release: European Medicines Agency launches new organisational structure and new visual identity. (8 Dec 2009).

http://www.ema.europa.eu

The Nobel Foundation statement said that the significance of Barre-Sinoussi and Montagnier’s achievements should be viewed in the context of a global ubiquitous epidemic affecting close to 1% of the population. The statement also said that the discovery of HIV was a prerequisite for current understanding of the biology of HIV/AIDS and antiretroviral treatment. It added, “This has allowed identification of important details in its replication cycle and how the virus interacts with its host. Furthermore, it led to development of methods to diagnose infected patients and to screen blood”.

Source: Kaiser Daily News (6 Oct 2008)
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=54829

Nobel Foundation Statement:
http://nobelprize.org/nobel_prizes/medicine/laureates/2008/press.html

An article in the New York Times referred to the award as a pointed rebuke of China’s ruling Communist Party that came as European leaders were arriving in Beijing for a weekend summit meeting. “Mr. Hu, 35, was given the prize by the European Parliament despite warnings from Beijing that his selection would harm relations with the European Union”.

Last year, Mr. Hu testified via video link before a hearing of the European Parliament about China’s human rights situation. Weeks later, Mr. Hu was jailed and later sentenced to three and a half years in prison on a conviction for subversion based on his critical writings about Communist Party rule.

Mr. Hu has been one of China’s leading figures on a range of human rights issues, while also speaking out on behalf of AIDS patients and for environmental protection. The European award comes after he had been considered a frontrunner for the Nobel Peace Prize, only to lose to the former president of Finland, Martti Ahtisaari.

Mr. Hu remains imprisoned in Beijing. His wife, Zeng Jinyan, a prominent blogger and human rights activist, has lived for months under house arrest with the couple’s infant daughter.

Source: NY Times (October 24, 2008).

Links:
http://en.wikipedia.org/wiki/Hu_Jia_(activist)
http://en.wikipedia.org/wiki/Zeng_Jinyan

“Due to international attention to Wang’s case, the authorities had been detaining Wang for a long time without trial to avoid scrutiny. While the world focused on the Olympics, the court rushed her to jail, perhaps hoping that no one would notice this travesty!” said Renee Xia, CHRD international coordinator.

Wang was detained on suspicion of “extortion” on November 27, 2007 while petitioning the provincial government in Zhengzhou, capital of Henan Province. Wang was detained for more than six months prior to her trial on June 12, 2008. Her case was twice sent from the Procuratorate back to the Public Security Bureau (PSB) for further investigation due to insufficient evidence.

AIDS organisations in China have called for Wang’s release and her case has received wide international attention. These organisations have, for example, brought Wang’s case to the attention of a member of the European Parliament visiting Beijing in June 2008. It is believed that the court tried and quietly delivered Wang’s verdict during the Olympics in the hope of evading international condemnation.

Wang has been detained to punish her for her persistent petitioning. Wang, 34, is a laid-off factory worker in the poverty-stricken Xincai County, an area ravaged by an AIDS epidemic after an unregulated blood plasma trade in which the government played a major role led to the rapid spread of the disease in the late 1990s. Wang became a petitioner and AIDS activist
after 2003 when it was discovered that her husband, Zhang, has been infected with AIDS. In 1996, Zhang, also a laid-off worker, had his right arm smashed at the paper-mill where he and his wife worked. Not only did he lose his job, he also contracted AIDS from a blood transfusion at the No.2 People’s Hospital at Xincai County. Prior to petitioning, Wang used all legal means to seek compensation for her husband, but the Court refused to accept her case.

The so-called “extortion” refers to Wang’s demand for compensation on behalf of her family after a nearby kiln polluted and damaged the family’s crops. After Wang complained to the relevant authorities, in the early half of 2007 Wang and the kiln’s owner reached a settlement and the latter paid RMB 4,800 in compensation. Months after the dispute was settled, Wang was detained.

• CHRD urges the Chinese authorities to immediately and unconditionally release Wang.
• CHRD believes that Wang has been incarcerated solely for the peaceful activities of petitioning. The authorities have abused Wang’s rights to freedom of expression guaranteed in Articles 19 of the International Covenant on Civil and Political Rights (ICCPR), which China has signed (but not yet ratified). This right is also enshrined in Article 35 of the Chinese Constitution.

Chinese Human Rights Defenders (CHRD) is a non-political, non-governmental network of grassroots and international activists promoting human rights and empowering grassroots activism in China. CHRD’s objective is to support human rights activists in China, monitor human rights developments, and assist victims of human rights abuses. CHRD advocates approaches that are non-violent and based on rule of law. CHRD conducts research, provides information, organizes training, supports a program of small grants to human rights activists and researchers, and offers legal assistance.

Human Rights and the Beijing Olympics 2008: “What can I do?”

Support CHRD’s “Free Olympics Prisoners” Campaign
http://www.crd-net.org/Article/Class9/class97/200803/20080326055056_8201.html

Support the campaign of Chinese citizens to end human rights abuses related to the Olympics by signing the petition “One World, One Dream and Universal Human Rights”
http://www.crd-net.org/Article/Class9/class97/200709/20070920050059_5310.html

Urge your government to speak up publicly about China’s rights violations. Press government leaders attending the Olympics opening ceremony not to go unless 1) China frees “Olympics Prisoners” and other prisoners of conscience and 2) lift censorship and surveillance of human rights activists.

Source: Chinese Human Rights Defenders (23 August 2008)
http://www.crd-net.org/Article

For an email newsletter for updates:
networkcrd@gmail.com

Doctor Arash Alaei and Doctor Kamiar Alaei have played a role in putting the issues of drug use and HIV/AIDS on Iran’s national health care agenda. They have worked closely with government and religious leaders to ensure support for education campaigns on HIV transmission, including those targeting youth, and for HIV and harm reduction programs in prisons.

Since completing their medical training, the brothers have worked in AIDS research in Iran, and along with other clinicians and advocates, helped make the country a leader in prevention and treatment of HIV and AIDS. They played a part in the creation of Iran’s HIV/AIDS prison program, one of the best in the region if not the world. The program passes out condoms and syringes in the prisons, one of only a handful of countries globally doing so. The doctors
have also shared their knowledge
with neighboring countries by holding training workshops for Afghan and Tajik health professionals.

Dr. Arash was scheduled to speak at the International AIDS Conference in Mexico City. A coalition of groups including PHR sponsored an empty chair with his name, to bring attention to the detention of the brothers. Dr. Kamiar, a doctoral candidate at the SUNY Albany School of Public Health, is expected to return to his program in September.

You can register a protest by signing this online petition calling on the Islamic Republic of Iran to either charge or immediately release Dr. Kamiar Alaei and Dr. Arash Alaei.
http://iranfreethedocs.org

Sources: Physicians for Human Rights
http://physiciansforhumanrights.org

IAS Press release:
http://www.aids2008.com/blog/free-iranian-hivaids-doctors

The position needs to be filled urgently and the starting date is likely to be October/November 2008.

For further information please contact Marc Lallemant, MD (ird@phpt.org or marc@phpt.org) at Programs for HIV Prevention and Treatment (PHPT). Tel: +66 (0) 5381 4270-1 or +66 (0) 5381 4633-8. Fax: + 66 (0) 5381 4269. PO Box 207 – Prasing Post, Muang, Chiang Mai 50205, Thailand

The magistrate court therefore dismissed the charges against the three and acquitted them.

On 4th June 2008, the three Human Rights Defenders were arrested during the just concluded HIV/AIDS Implementers meeting in Kampala. They were objecting to the exclusion of Sexual Minorities from the HIV/AIDS Prevention programmes in the country.

After two days and nights of detention in police cells, the activists were charged with Criminal Trespass, a charge that carries a one year jail term according to section 302 of the Penal Code of Uganda. They were released on bail on the 6th of June 2008. They appeared in court for several hearings, before the court acquitted them of the above charges SMUG and the entire LGBTI community of Uganda would like to express our gratitude to you all for the love and support.
Thank you

Source: Sexual Minorities Uganda (SMUG) (15 August 2008).
http://www.sexualminoritiesuganda.org

Senior BSO tutor Paul Blanchard and his team have also, since 20005, run a free Friday afternoon osteopathy service at
the Ian Charleston Day Centre at the Royal Free Hospital in Hampstead, north west London. From 1 April 2008 treatment at the BSO Chapman Clinic will be offered from the new clinical centre that the BSO is opening at 98-118 Southwark Bridge Road (SE1 0BQ) just a few minutes’ walk from its existing premises.

The BSO is keen to ensure that anyone living with HIV who might be helped by osteopathic treatment are aware of the free treatment it can offer them. Osteopathy is a primary healthcare system, complementary to other medical practices. It is suitable for almost anyone and can contribute to alleviating an enormous range of conditions.

Osteopaths primarily work mostly on muscles and joints, and pay special attention to how the internal organs affect, and are affected by, that system. Relevant psychological and social factors also form part of the diagnosis. Another important principle of osteopathy is that the body has its own self-healing mechanisms, which can be utilised as part of the treatment.

Osteopathic treatment at the BSO Chapman Clinic and at the Ian Charleston Day Centre is provided by osteopathic students supervised and supported by tutors who are qualified osteopaths, and who have a specialist interest in HIV, drug therapies,

associated pathologies and the musculo-skeletal presentation of HIV. Anyone living with HIV can refer themselves to these clinics.

Osteopathic treatment for people living with HIV/AIDS can bring great improvements in quality of life by addressing the particular musculo-skeletal dysfunction they often experience. It also complements the drug therapies used to manage HIV/AIDS and may also help in coping with the side effects they can bring.

To book treatment contact either clinic directly.

BSO Chapman Clinic: 020 7089 5360
clinicappointments@bso.ac.uk

Peter Duesberg and Celia Farber had travelled to Washington, D.C., from California to receive an award for their efforts to discredit factual evidence about HIV and HIV treatment. “These aren’t whistleblowers,” said a Washington DC, HIV activist.“They’re divergent thinkers who are 21st century snake-oil salesmen.”

Source: thebody.com

Want to test your luck at “Pos or Not”?
http://www.thebody.com/content/art46888.html?mtrk=8203834

IAS President, Pedro Cahn, referred to Mr Jia’s sentence as a failure of justice.

“Hu Jia is highly respected as a human rights activist all over the world. He has dedicated his life to fighting against injustice in China, at great personal risk. His continued harassment by authorities, arrest and subsequent sentencing is a violation of his human rights, and an insult by the Chinese authorities to the global human rights movement,” said Dr Cahn. “We are also concerned for Hu’s health. He needs daily medication for his hepatitis infection and is in the early stages of sclerosis of the liver.”

Hu is most widely known as an advocate for the rights of people living with HIV/AIDS in China, and has been honoured with a number of international awards for his efforts. His work on HIV/AIDS is widely credited within China amongst government authorities and civil society groups. According to available information, Hu’s conviction and sentencing are not in relation to his HIV/AIDS work.

“This is the time for China to be improving its image. The eyes of the world are on Beijing ahead of the Olympic Games, and we urge the Chinese government to seize this opportunity to improve its record on human rights, and release Hu Jia immediately,” said Dr Cahn.

On 2 April, Hu was sentenced to three and half years in prison on charges of subversion. He was convicted in a trial last month.

The IAS is the world’s leading independent association of HIV professionals, with more than 10,000 members from 172 countries. The IAS is a non-profit organization founded in 1988, and acts as an independent voice in the global response to AIDS on behalf of its members.

Source: IAS press release (April 2008)

“The 2003 war on drugs is notorious for the crimes against humanity perpetrated by Thai authorities,” said Karyn Kaplan, Director of Policy and Development for Thai AIDS Treatment Action Group (TTAG). “We are horrified that Thailand would re-launch such a disastrous government policy.” In addition to gross human rights violations, the 2003 drug war seriously disrupted drug users’ access to essential services, such as HIV treatment, prevention information, counseling and equipment, by driving drug users even further underground.

Thai AIDS activists want to highlight the important role that UNAIDS can play in advocating to governments to provide lifesaving prevention and targeted treatment services to highly vulnerable groups, including migrant workers, undocumented citizens and people who use drugs. Without addressing the specific needs and challenges faced by these groups, the goal of universal access can not be achieved.

“The Thai war on drugs will have disastrous consequences for the fight against AIDS in Thailand – and it will not work as a response to drug use in Thai society,” said Kriengkrai Aiemprasert, outreach worker at Ban Mit Sampan Harm Reduction Center in Bangkok. “The Thai Prime Minister should end the war on drugs, and promote a response to drug use based on evidence, and human rights.”

An estimated 50% of drug users in Thailand are HIV-positive. HIV incidence and prevalence in Thailand has declined overall, but not among people who use drugs or other highly vulnerable groups including men who have sex with men (MSM). Experts attribute this to the Thai government’s resistance to comprehensive harm reduction policy and programming, along with their reluctance to include drug users in the design and implementation of treatment and prevention programs.

“Fighting HIV in Thailand requires evidence-based interventions
for people who use drugs,” said Paisan Suwannawong, director of the Thai AIDS Treatment Action Group (TTAG) and a former intravenous drug user. “We urgently need an effective response – instead the government has pledged to crack down on drugs and told us that we should expect more murders. The Prime Minister, Samak Sundaravej himself said killings are ‘impossible to avoid’ in a drug war. This kind of message is unacceptable and , essentially, a license to kill.”

During the 22nd UNAIDS’ Programme Coordinating Board (PCB) meeting, civil society representatives from different organizations of HIV and TB affected communities held a major demonstration against the Thai new drug control policy.

This brief update and a collection ofpPhotographs about this demonstration are available at http://www.hdnet.org/v2/home

Source: Press Release, Thai AIDS Treatment Action Group (TTAG).

“It is unacceptable that for the second time, a critical forum for addressing the AIDS epidemic has been held in a country that bans medicines proven to prevent HIV,” said Raminta Stuikyte of the Eurasian Harm Reduction Network.

“Hundreds of people across Eastern Europe and Central Asia rely on methadone and buprenorphine to improve their lives. These important voices have been shut out of the conference yet again,” added Dr. Konstantin Lezhentsev of All-Ukrainian Network of People Living with HIV.

Methadone and buprenorphine, which are on the World Health Organization’s Model List of Essential Medicines, are prescribed in many countries throughout the region, where injection drug use accounts for more than 70 percent of cumulative HIV cases. Many AIDS activists from these countries, including Azerbaijan, Belarus, Estonia, Georgia, Kyrgyzstan, Latvia, Lithuania, Moldova, Ukraine, and Uzbekistan, were unable to attend the conference because they are undergoing methadone or buprenorphine treatment.

In advance of the conference, drug user community activists and harm reduction providers in Ukraine produced video testimonials of people who are on buprenorphine treatment to be shown in the conference community space. The people in the video discuss how the treatment has helped them stabilize their lives and stop injecting drugs. They also express frustration at being shut out of the AIDS conference.

“The failure of global health leaders to ensure the full participation of communities highly affected by HIV directly undermines the goals of the conference,” Stuikyte added.

The petition is available online in Russian

Source: EHRN press release (Eurasian Harm Reduction Network, 3 May 2008).

ICEHA is an international not-for-profit organization that engages healthcare professionals to rapidly transfer their expertise on HIV care and infectious diseases to colleagues in developing countries, using an innovative method of clinical mentoring. Unlike other organizations, ICEHA volunteer clinical mentors do not provide patient care directly. Instead, they equip local caregivers with the skills needed to take care of their own patients. As a result, thousands of patients receive HIV care when none existed before, care delivered by their own healthcare providers, within existing resource limitations.

More information, including a volunteer application, is available online or by emailing volunteer@iceha.org

The report, entitled ‘I count myself as being in a different world: African gay and bisexual men living with HIV in London’, has just been released by the Centre of Sexual Health and HIV at Homerton University Hospital NHS Foundation Trust. It highlights that the additional stigma of being gay or bisexual and HIV positive is difficult for African men. However, life in London offers some benefits to men in this situation, including access to healthcare and more liberal sexual attitudes in the Capital.

The report shows that the dual stigma of being gay or bisexual and having HIV causes a dilemma when African men consider disclosing their condition. Author Professor Lesley Doyal said: “Our study shows that being HIV and gay or bisexual has created very complex social lives for African men, with many developing and having to manage different groups of friends who will either know some, all or nothing about their situation. Those who are open about being gay or bisexual and HIV tend to only go where this is accepted, sometimes losing contact with their own communities.”

The report highlights that African gay or bisexual men with HIV face additional difficulties to other gay/bisexual men with HIV, because of the expectations surrounding their cultural identity. This has created a new set of practical and emotional needs, which sometimes cannot be met, particularly for those with little money or insecure immigration status.

This report is third in a series of projects describing the experiences of African people living with HIV in London.

It is available to download:

http://www.homerton.nhs.uk/education/11924649825796.html

Researchers from City University London and Homerton are now appealing for African men who have sex with men to take part in a major new national study. The project, Men and Sexual Health (MESH), will investigate whether sexual health services in Britain meet the needs of ethnic minority men who have sex with other men (MSM) including men of African origin.

The questionnaire is online at.

http://www.meshproject.org.uk

The two previous reports in this project are:

Doyal, L & Anderson, J (2003) ‘My heart is loaded’: African women with HIV surviving in London

Doyal, L, Anderson J & Apenteng, P (2005) ‘I want to survive, I want to win, I want tomorrow’: an exploratory study of African men living with HIV in London

Online versions of both reports are available:

http://www.homerton.nhs.uk/education/11604037592768.html

IAS believes this ruling:

1. Undermines United States Government’s current efforts in providing global leadership on the response to HIV/AIDS;
2. Promotes a discriminatory bias in selecting waivers for short-term visitors to the United States who are living with HIV; and,
3. Promotes a policy that has no plausible basis in science, public health and medicine.

As a network of more than 10,000 professionals from around the world working in research, treatment, care, support and prevention services on HIV/AIDS, the IAS is the world’s largest network of HIV professionals. Our members hail from around the world, including more than 2,500 members in the United States.

We were encouraged in December 2006, when President George W. Bush announced on World AIDS Day that the White House would issue an executive order allowing HIV-positive people to enter the U.S. on short-term visas without seeking a special waiver. That executive order never materialised.

From our perspective, the latest proposal from the Department of Homeland Security to “streamline” the visa waiver process for HIV-positive persons wishing to enter the United States, only serves to reinforce a bad policy that is clearly discriminatory and has no public health basis.

Furthermore, this new “streamlined” policy, (please see our attached comments on the specifics of the ruling) undermines the United States Government’s credibility as the global leader in resource-provision for HIV prevention, treatment, care and disease mitigation.  Because the United States’ leadership has made HIV prevention, treatment and care services more available around the world, this policy says to people living with HIV in those most affected countries, “here is your funding for HIV services, now stay away from our borders.”

We firmly believe there is no sound public health reason to single out HIV as a basis for inadmissibility to the United States or any other country.  The majority of nations in the world do not have this type of discriminatory statute in their visa laws, because they have found that allowing HIV-positive persons to enter their borders poses no imminent threat to their population.

Holding on to, and “streamlining” this antiquated policy, puts the United States in line with only 13 other countries that “ban” HIV-positive persons from entering their borders on a short-term visitor basis – Iraq, China, Saudi Arabia, Libya, Sudan, Qatar, Brunei, Oman, Moldova, Russia, Armenia, and South Korea.

Because there is no public health rationale for this policy, the only plain effect  could be to target men, women and children from countries most affected by HIV (who are predominantly persons of color), gay men, and people who are from other socially marginalized groups, from entrance into the United States.

This is deplorable. The International AIDS Society urges the United States Government, through the Department of Homeland Security, to table this proposed ruling and to hold a rigorous and evidence-based public review of this statute instead of advancing a bad policy that undermines the United States leadership and credibility.

For more information on the IAS, please visit:

http://www.iasociety.org

Source: IAS press statement “Statement on United States Department of Homeland Security proposed ruling to “Streamline” temporary visa provision for people living with HIV/AIDS”. December 4, 2007

NAT is keen to evaluate both the impact of the dispersal booklet and how the new dispersal process is working through a short online evaluation form.

Your feedback is helpful as NAT prepares a brief in response to a forthcoming Home Office review of the dispersal process. All information provided in this evaluation form will be treated in confidence.

You may access and submit the form online by visiting:

http://www.nat.org.uk/HIV-Testing-%26-Care/Migration-policy/

You may also download the form (from the same web link) and return it completed either by e-mail (dispersal@nat.org.uk) or by post to: Policy and Campaigns Team, National AIDS Trust, New City Cloisters,  196 Old Street, London EC1V 9FR.

The booklet ‘The Dispersal Process for Asylum Seekers Living with HIV – Advice for health care and voluntary sector professionals’ is available online as a PDF

http://www.nat.org.uk/document/208

There is a clear contradiction between this policy and the UK’s policy aim of universal access to HIV treatment for all those who need it by 2010. The withdrawal of treatment increases the body’s vulnerability to opportunistic infection and will result in drastically shortened life expectancy.

The AHPN believes that there are strong public health arguments for allowing a concession.  Those awaiting removal may go underground and fail to keep appointments resulting in an increased risk of opportunistic infection with the need for emergency treatment and an increased risk of onward transmission.  The Department of Health has valued the prevention of one single onward transmission as between £500,000 and £1 million in terms of individual health benefits and treatment costs.

The AHPN’s ‘Destination Unknown’ Campaign is calling on the Home Office to delay the deportation of people living with HIV from the United Kingdom until antiretroviral treatment becomes more widely available.

The AHPN is also asking MPs to support the campaign by endorsing Early Day Motion 1556.

Please write to your local MP and encourage others (friends, colleagues, service users) to do likewise. If you are not sure who your local MP is, you can access this information at:
http://www.parliament.uk/people/index.cfm

You can then check if they have already signed the EDM by going to the EDM website:
http://edmi.parliament.uk/EDMi/EDMDetails.aspx?EDMID=33357&SESSION=885

For further information see the AHPN website:
http://www.ahpn.org/campaigns/index.php?camp_id=7”

Tuberculosis outbreaks in the developed world are newsworthy. [1] However, in the developing world, where deaths from tuberculosis are common, it takes something exceptional for an outbreak to attract much attention. In response to a recent report at the 16th international AIDS conference [2] and to increasing South African media reports, the World Health Organization last week expressed concern about extensively drug resistant tuberculosis (also referred to as “XDR tuberculosis”). [3]

Among 536 culture confirmed cases of tuberculosis at a rural hospital in South Africa, 41% were multidrug resistant, [2] defined as resistance to rifampicin and isoniazid (two key first line drugs). This is cause enough for concern as multidrug resistant tuberculosis has a worse outcome and its management is very difficult even in high resource settings. [4 ] Even more alarming was that 53 (24%) of the isolates from multidrug resistant tuberculosis fulfilled the definition of extensively drug resistant tuberculosisónamely, multidrug resistant tuberculosis that is also resistant to at least three of the six classes of second line agents. Such tuberculosis is virtually untreatable.

All patients in this outbreak who were tested were HIV infected, and 52 of the 53 died after a median of just 25 days. In 90% of the isolates the same genetic fingerprint was present, indicating extensive recent transmission. Fifty six per cent of patients had previously been admitted to hospital, raising the likelihood of nosocomial transmission.

Outbreaks of infectious diseases are always more newsworthy if their implications extend beyond the local context, which is the case with extensively drug resistant tuberculosis. For some years, such strains have been known to exist in Asia, North and South America, and Europe. In March this year, the Centers for Disease Control and Prevention and WHO reported a survey of over 17 000 tuberculosis isolates collected from around the world between 2000 and 2004.5 Overall, 2% of multidrug resistant strains were also extensively drug resistant, being most frequently found in eastern Europe, western Asia, and South Korea. Population based data from the United States, Latvia, and South Korea showed that 4%, 19%, and 15% respectively of multidrug resistant strains could be defined as extensively drug resistant.

The epidemiology and the limited genotypic data currently available [2, 6] indicate that this is not a single strain, but that extensively drug resistant strains are likely to have emerged in many different places and on multiple occasions. Paradoxically, this is both reassuring and alarming. It is reassuring in that the emergence of extensively drug resistant tuberculosis in more than one strain suggests that the mutations responsible are specific for drug resistance rather than reflecting a fundamental change in behaviour of the organism. This is nevertheless alarming because it also suggests that extensively drug resistant tuberculosis probably arises fairly regularly and is already disseminated.

Drug resistance to tuberculosis results largely from poorly managed care and control of the disease. Poor prescribing practices, low drug quality (or erratic supply), and suboptimal adherence can all contribute to this. Bacilli are subject to intense drug selection, and exposure to mono-therapy predisposes to an accumulation of mutations that confer resistance. Hence optimal treatment includes four drugs to which the organism is sensitive, and a single drug should never be added to a failing regimen. In much of the world, routine culture and sensitivity testing is not available. Thus, where multidrug resistant tuberculosis emerges, inappropriate treatment regimens may lead to serial acquisition of resistance mutations, with potential for emergence of extensively drug resistant tuberculosis. Widespread use of second line tuberculosis drugs (such as quinolones for respiratory tract infections) may also contribute to the development of resistance. Thus, the emergence of extensively drug resistant tuberculosis should come as no surpriseóit was entirely predictable in the context of poor control practices.

The havoc that institutional transmission of multidrug resistant tuberculosis can wreak amongst HIV infected people was evident in the US in the early 1990s. [7] The very modest actual rise in the incidence of tuberculosis that coincided with these outbreaks has now been reversed, [8] albeit with extraordinary effort and cost. However, the huge potential for extensively drug resistant tuberculosis to further undermine control practices in communities in South Africa and elsewhere in the region is self evident and would be much more difficult to control. In some communities with an antenatal prevalence of HIV of 30%, annual notification rates for tuberculosis have already increased uncontrollably over the past 10 years, reaching 1500/100 000óa rate more than 250 times higher than rates in the US. [9] Extensively drug resistant tuberculosis must now serve as a serious wake-up call. Although the potential consequences may be most grave in settings with a high prevalence of tuberculosis and HIV, extensively drug resistant tuberculosis is nevertheless already a very serious development in many other parts of the world too. [5]

What response is needed? The global scale and molecular epidemiology of extensively drug resistant tuberculosis require urgent assessment, and laboratory capacity needs to be greatly increased within a network of sentinel sites. Control practices must be rigorously and effectively implemented. Increasing cure rates for tuberculosis through directly observed treatment short course (DOTS) is crucial. Detection rates for cases of tuberculosis need to be improved, highlighting the need for a new diagnostic test. Technologies that can determine the presence of drug resistance at the point of care are needed, as are new drug treatments. The DOTS-Plus strategy [10] for treatment of multidrug resistant tuberculosis needs to be further developed for areas where the disease is established. Nosocomial transmission of tuberculosis is probably commonplace in the developing world, and simple, effective strategies to reduce such transmission need to be urgently implemented. More fundamentally, the emergence of extensively drug resistant tuberculosis is a reminder that tuberculosis needs massive broader commitment: the incompletely funded Global Plan to Stop TB [11] demands political will and financial action.

COMMENT

This recent BMJ editorial relates to the IAC Toronto study. The references are useful for important related documents.

Source:  www.bmj.com

Lawn SD. Extensively drug resistant tuberculosis: A serious wake-up call for global health. Editorial BMJ 2006;333:559-560 (16 September), doi:10.1136/bmj.38971.587222.AB
http://bmj.bmjjournals.com/cgi/content/full/333/7568/559

References

1. Watson JM, Moss F. TB in Leicester: out of control, or just one of those things? BMJ 2001;322: 1133-4.
2. Ghandi NR, Moll A, Pawinski R, Sturm AW, Lalloo U, Zeller K, et al. High prevalence and mortality from extensively-drug resistant (XDR) TB in TB/HIV coinfected patients in rural South Africa. Abstracts of the 16th international AIDS conference, 13-18 August 2006. Toronto, Canada: International AIDS Society, 2006. (Abstract THLB0210.)
3. World Health Organisation. Emergence of XDR-TB. WHO concern over extensive drug resistant TB strains that are virtually untreatable.
http://www.who.int/mediacentre/news/notes/2006/np23/en/index (accessed 10 Sep 2006).
4. Mukherjee JS, Rich ML, Socci AR, Joseph JK, Viru FA, Shin SS, et al. Programmes and principles in treatment of multidrug-resistant tuberculosis. Lancet 2004;363: 474-81.
5. Emergence of Mycobacterium tuberculosis with extensive resistance to second line drugs worldwide, 2000-2004. MMWR Morb Mortal Wkly Rep 2006;55: 301-5.
6. Masjedi MR, Farnia P, Sorooch S, Pooramiri MV, Mansoori SD, Zarifi AZ, et al. Extensively drug-resistant tuberculosis: 2 years of surveillance in Iran. Clin Infect Dis 2006;43: 841-7.
7. Frieden T, Sterling T, Pablos-Mendez A, Kilburn J, Cauthen G, Dooley S. The emergence of drug-resistant tuberculosis in New York City. N Engl J Med 1993;328: 521-6.
8. Trends in tuberculosisóUnited States, 1998-2003. MMWR Morb Mortal Wkly Rep 2004;53: 209-14.
9. Lawn SD, Bekker LG, Middelkoop K, Myer L, Wood R. Impact of HIV on epidemiology of tuberculosis in a peri-urban community in South Africa: the need for age-specific interventions. Clin Infect Dis 2006;42: 1040-7.
10. Farmer P, Kim JY. Community based approaches to the control of multidrug resistant tuberculosis: introducing “DOTS-plus.” BMJ 1998;317: 671-4.
11. Stop TB partnership. The global plan to stop TB 2006-2015. Executive summary. 2006.
http://www.stoptb.org/globalplan/assets/documents/GP_ES_Eng.pdf (accessed 10 Sep 2006).

“The need for early identification and treatment of TB is desperately urgent,” says the UN Secretary-General’s Special Envoy for AIDS in Africa, Stephen Lewis, in the foreword to the report. “We must never forget that in many countries, the majority of people who die of AIDS succumb to tuberculosis. TB and HIV act on each other with fatal forceóa combination made in hell, which must be expunged from the catalogue of communicable disease.”

Through a review of TB and TB/HIV policy, and extensive consultation with policymakers, activists, and patients, the report reveals that the interaction between TB and HIV/AIDS is particularly deadly in many sub-Saharan African countries due to widespread stigma, low levels of awareness, poorly coordinated services, and a lack of mobilization at the local, national and international levels.

In Tanzania, for example, the number of TB cases increased by almost six-fold between 1983 and 2003, from approximately 12,000 cases to 64,500, with 60 percent of the increase in TB incidence attributable to HIV.

HIV/AIDS is also fuelling the TB epidemic in Nigeria, the nation with the largest number of new TB cases in Africa, with a 6 percent annual increase in TB prevalence, and a four-fold increase in HIV rates among people living with TB between 1991 and 2001.

While Bangladesh, Brazil, Nigeria, Tanzania, and Thailand face varying rates of TB/HIV coinfection, the report points to the need for decisive governmental action to coordinate TB and HIV/AIDS policies and programs, both in countries with high coinfection rates such as Tanzania, as well as in countries at high risk for a burgeoning coepidemic such as Bangladesh.

In all five countries examined, people living with HIV/AIDS face serious obstacles to receiving prompt, effective treatment for TB, including lack of proper diagnostic tools.

Brazilian Public Health Watch researcher Ezio T·vora dos Santos Filho, who is living with HIV and has survived TB twice, asserts that even in middle-income Brazil, “only an individual with good connections and access to top-quality medical assistance (including rapid TB diagnostic tests) can survive a complex TB/HIV coinfection.

While the report emphasises that community mobilisation has proven essential in advocating for research, development of new tools, and increased resources for the fight against HIV/AIDS, the people and communities most affected by TB often lack resources and opportunities to engage in policy processes. TB-associated stigma also reduces advocacy on the disease.

Greater social mobilisation around TB and TB/HIV will be essential to reduce TB and TB-related deaths among people living with HIV/AIDS. According to the report, this will not occur without a concerted and sustained effort on the part of donors, policymakers and community activists to engage TB and HIV patients as partners.

This report – which focuses specifically on TB/HIV policy and the effects of the HIV/AIDS epidemic on TB control efforts – is a preview of a series of in-depth studies of the five countries that will be launched on Nov. 1, 2006, at the annual International Union Against Lung Disease Conference in Paris.

Source: Press release, Public Health Watch

A copy of the study is available at:

http://www.publichealthwatch.info

Recent legal cases concerning HIV transmission have raised complex questions for both clinicians and service users about rights, responsibilities and legal obligations to disclose information to others.

Clinicians working with people living with HIV are faced with situations that can bring various social values, including civil liberties, public health concerns, confidentiality, autonomy, and discrimination, into conflict.  Although established generic ethical and professional principles continue to apply, certain features of the HIV epidemic have required special consideration.

For an effective therapeutic relationship to be established and maintained people living with HIV and their clinical carers must be able to discuss any relevant matter openly. An underlying principle in the provision of clinical care for people with HIV is the need for a secure and confidential environment in which extremely sensitive matters can be frankly and fully discussed.

The importance of ensuring that full trust is maintained by people with HIV in their clinical services in the light of the introduction of the criminal law into the HIV arena is fundamental, not only for the health of people living with HIV but also for people who may wish to seek information or testing and thus for the wider public health.

This paper focuses on the responsibilities and duties of health care staff in the knowledge that other sources of information on this matter exist for other audiences, including people living with HIV (see appendices for references and for additional sources of information).

http://www.bhiva.org

An article in the 8 June edition of New England Journal of Medicine has drawn attention to important recent changes in the US regulatory requirements.

From 30 June the FDA requires new rules on information that have been publicised as measures to increase patient safety. These include label changes to reorganise information including highlighting most commons safety concerns and adding a table of contents.

The urgency of these small changes are perhaps highlighted by the timetable for changes. Drugs already licensed will have 3-7 years to implement similar label changes, and drugs approved prior to 2001 are excluded altogether.

All these changes were open to an extended period of consultation, but after this closed, a new section was added that protects companies from legislation for purposes of litigation. The wording is such that it virtually preempts any litigation by patients who are injured from using a drug, even if the company failed to adequately warn patients of a known risk, unless they can prove that the company intentionally committed fraud.

The article also negatively compares the professional reference manual for drug listings in the US (the pharma-sponsored Physician’s Desk Manual) with the British National Formulary (www.bnf.org), for grouping drugs by manufacturer rather than by class (preventing easy comparisons within a drug class) and for financial links with industry.

Additionally, for an organisation that is apparently interested in increasing patient safety and risk awareness, the article highlights how difficult the FDA website is to when trying to access information.

COMMENT

The US pharmaceutical lobby have been trying to reduce options for legal liability for several years. It is difficult to see how challenges to this legislation could be effective in the current US political climate.

Ref: Avorn J, Shrank W. Highlights and a hidden hazard – the FDA’s new labelling regulations. NEJM 8 June 2006. 354 (23):2409-2411.

Over 300 cases of the sexually transmitted infection (STI) lymphogranuloma venereum (LGV) have been diagnosed in the United Kingdom, according to figures presented to a sexual health conference on May 10th. Nearly all the cases involved gay men, many of whom were HIV-positive. Co-infection with other sexually transmitted infections such as hepatitis C virus, was also common.

LGV is a form of chlamydia, and although endemic in many parts of the world, it was rarely seen in Europe and North America after the introduction of antibiotics. However, in 2004 a cluster of LGV infections was seen amongst gay men who had attended sex parties in the Netherlands. The infection was quickly disseminated across western Europe and cases have also been reported in the United States.

In October 2004, enhanced national surveillance of LGV was commenced in the United Kingdom and investigators from Imperial College, University of London, presented data on the epidemiology of the infection in the United Kingdom, based upon reports received until the end of March 2006.

The investigators reported that a total of 341 cases of LGV had been diagnosed in the United Kingdom with detailed information being available for 283 cases. All but three of these cases involved gay men. The LGV epidemic was focused in London, where almost three quarters of infections were located. A secondary focus of the infections was Brighton (14%), with the remaining cases distributed across the country.

Most patients (94%) presented with symptoms of inflammation of the rectum (proctitis), although 30% also had flu-like symptoms and in a small proportion of individuals (3%) the infection was silent.

Source: aidsmap.com

LGV Special report in HTB (July 2005):

http://www.i-base.info/htb/3137

6 April 2006

Category: URGENT

Improving the Prevention and Treatment of Sexually Transmitted Infections (STIs), including HIV

Dear Colleague,

I am writing to update you on some of the elements of clinical good practice on sexual health and, in particular, the more serious sexually transmitted infections (STIs) such as HIV. I would be grateful if you could bring this advice to the attention of your relevant management colleagues, clinical and public health teams so they can take any necessary action to safeguard the health of your local population.

Good practice standards in relation to both sexual health and HIV services have been published [1, 2]. In addition, ‘The NHS in England: the operating framework for 2006/07’ [3], prioritises action on sexual health and access to genito-urinary medicine (GUM) services, so that by 2008 everyone should be able to have an appointment within 48 hours. Building on this good practice and improving access to sexual health services has particular benefits for HIV prevention.

As well as general prevention work, it is important also to consider postexposure prophylaxis (PEP) which can prevent HIV transmission taking place after non-occupational exposure to HIV. PEP is an emergency treatment, and to be effective in preventing HIV, it must be prescribed as soon as possible after potential exposure to the virus. After 72 hours it is unlikely to be effective. The British Association for Sexual Health and HIV (BASHH) has recently published new clinical guidelines, including those for risk assessment, on prescribing PEP following non-occupational exposure [4]. ‘Recommended standards’ also includes guidance on the provision of PEP after non-occupational HIV exposure [1, 2].

I would therefore ask you to ensure that PEP is part of the spectrum of sexual health services for your local populations. Provision of PEP for nonoccupational exposure is not a replacement for evidence-based HIV health promotion, but it can have a contribution to make in preventing transmission of HIV.

Sir Liam Donaldson,

Chief Medical Officer

References

1. ‘Recommended Standards for NHS HIV Services’ (2003) produced by the Medical Foundation for AIDS and Sexual Health
http://www.medfash.org.uk/publications/current.html
2. ‘Recommended Sexual Health Standards’ (2005), produced by the Medical Foundation for AIDS and Sexual Health
3. The NHS in England: The operating framework for 2006/7
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/
PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4127117&chk=BgslVK
4. United Kingdom Guideline for the use of post-exposure prophylaxis for HIV following sexual exposure (BASHH) 2006

COMMENT

Unfortunately, this letter is much more likely to have been prompted by an individual challenging the government in court, for not providing access to PEP, than the recent publication of PEPSE guidelines by British Association for Sexual Health and HIV (BASHH).

Hopefully, the letter (alongside the guidelines) will help to ensure that clinics now provide PEP, that it is publicised more widely, and that it is appropriately funded – without which, nothing will change. This is not clear in the current payment-by-results (PBR) tariffs.

Several presentations at the BHIVA Conference emphasised that PEP can only work if people know about it, and that awareness in both HIV-positive and HIV-negative individuals was not extensive.

Links:

BASHH guidelines on use of PEPSE (February 2006):
http://www.bashh.org/guidelines/2006/pepse_0206.pdf

Letter available as pdf download:
http://www.bashh.org/guidelines/cmo_letter60404133099_110406.pdf

The survey found that in 2005, 79% of people surveyed knew that HIV can be transmitted through unprotected heterosexual sex compared with 91% in 2000. In addition, 73% knew that HIV can be transmitted through contaminated needles, compared with 88% in 2000. The percent of people reporting no knowledge of how HIV is transmitted rose from 6% in 2000 to 8% in 2005.

In addition, 7% of people who participated in the 2005 survey incorrectly believed the virus can be transmitted through spitting, 4% incorrectly believed it can be transmitted through kissing and 2% incorrectly believed it can be contracted from toilet seats. About 40% of respondents said they always use a condom with a new partner, and one in eight said they would ask a new partner to get tested for HIV or another sexually transmitted infection before having sex without a condom.

In London, an area which has the highest HIV prevalence in the country, 70% of residents knew that HIV can be transmitted through unprotected heterosexual sex and 57% believe the virus can be transmitted through contaminated needles. The survey also indicates that people who know more about the disease tend to be less prejudiced toward HIV-positive people.

For a full copy of the Ipsos MORI report or to arrange interviews contact Emma Bickerstaff on 020 7814 6730.

National Aids Trust:
http://www.nat.org.uk

Source: KaiserNetwork.org

ICEHA is a non profit organisation of healthcare professionals who volunteer to transfer their expertise on HIV care and infectious diseases to colleagues in developing countries. Using an innovative method of clinical mentoring , ICEHA’s program specifically results in the rapid scale-up of skills of the local healthcare staff AND strengthening the quality of healthcare delivered in developing countries so that countries can fight the HIV epidemic from within.

More information, including a volunteer application, is available online or by emailing Katie Graves-Abe at: kgravesabe@iceha.org

The new “Stop TB Strategy” addresses the current challenges facing countries in responding to TB: how to continue scaling-up TB control while also addressing the spread of TB and HIV coinfection and multidrug-resistant TB (MDR-TB). Coinfection in Africa, and MDR-TB in Eastern Europe, are seriously hampering efforts to reduce the annual 1.7 million TB deaths.

At the strategy’s core is DOTS. Since its launch in 1995, more than 22 million patients have been treated under DOTS-based services. The six strategies in the Stop TB Strategy are:

• Pursuing high-quality DOTS expansion and enhancement.
• Addressing TB/HIV, MDR-TB and other challenges.
• Contributing to health system strengthening.
• Engaging all care providers. To be able to reach all patients and ensure that they receive high-quality care, all types of health-care providers are to be engaged.
• Empowering people with TB, and communities. Community TB care projects have shown how people and communities can undertake some essential TB control tasks. These networks can mobilise civil societies and also ensure political support and long-term sustainability for TB control programmes.
• Enabling and promoting research. Improved elimination will depend on new diagnostics, drugs and vaccines.

The new Stop TB Strategy underpins the Global Plan to Stop TB, 2006-2015, an ambitious US$ 56 billion action plan launched in January. If fully implemented, the Global Plan will treat 50 million people for TB, halve TB prevalence and death rates and save 14 million lives.

Details of the new Stop TB Strategy are published in the Lancet as part of a special TB essay focus prior to World TB Day, which is held every year on 24 March.

Source: WHO press release

http://www.who.int/mediacentre/news/releases/2006/pr12/en/index.html

COMMENT

The strategy emphasises TB/HIV coinfection and MDR-TB, and is the first time a TB strategy recognises the important role that patient communities can play in programme improvements.

A broad community supported website promptly collected and published online a useful collection of articles presenting the scientific evidence that HIV is the cause of AIDS, and that benefits of antiretroviral drugs (ARVs) outweigh the risks. The website was created by people engaged in the worldwide struggle against HIV/AIDS and is an excellent resource.

This website presents the scientific evidence that HIV is the cause of AIDS

http://www.aidstruth.org

Links include original Harpers article and media response (from The Nation, Salon, New York Times, The Advocate and others):

http://www.aidstruth.org/Harpers_Out-of-Control-Article_March-2006.pdf

Harper’s Publishes AIDS Denialist

http://www.thenation.com/blogs/notion?pid=65330

Contributing to genocide

http://archive.salon.com/health/feature/2000/07/28/aidsdeniers/index.html

The New York Times

http://www.nytimes.com/2006/03/13/business/media/13harpers.html?_r=1

HIV Denialism in Harper’s Faulted

http://www.gaycitynews.com/gcn_509/hivdenialismin.html

Harper’s magazine publishes controversial AIDS story

http://www.advocate.com/news_detail_ektid27946.asp

Evidence HIV Causes AIDS

http://www.niaid.nih.gov/factsheets/evidhiv.htm

The Science of HIV/AIDS

http://www.aidstruth.org/Science-of-HIV-AIDS-TAC.pdf

The Relationship Between HIV and AIDS

http://www.niaid.nih.gov/factsheets/howhiv.htm

How HIV Causes AIDS (Koch’s Postulates etc)

http://www.sciencemag.org/feature/data/cohen/266-5191-1647a.pdf

HAART decreases mortality

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16514305&dopt=Abstract

Facts, resources and links

http://www3.niaid.nih.gov/news/focuson/hiv/resources/default.htm

AIDS Denialists: How to Respond

http://www.aegis.org/pubs/atn/2000/atn34210.html

Part of an effort to manage the risks of medication use and reduce medical errors, the newly designed package insert will provide the most up-to-date information in an easy-to-read format that draws attention to the most important pieces of drug information, thus reducing the complexity of information on prescription drug labels. The new format will also make prescription information more accessible for use with electronic prescribing tools and other electronic information resources.

The new drug labeling requirements will be phased in gradually, and initially will apply to newly and recently approved prescription drugs and drugs that receive approval for new uses. The agency is encouraging drug makers to consider complying with the new labeling requirements earlier on a voluntary basis. All drugs approved within the past five years are included, and they will gradually be converted to the new prescribing information format.

The new format requires that the prescription information for newly approved products, and those approved within the last five years, meet specific graphical requirements, including the reorganisation of critical information so medical professionals can find the information they need quickly.

As prescription information is updated in this new format it will be added to a new online health information clearinghouse called DailyMed that will provide up-to-date medication information free to consumers, healthcare professionals and healthcare information providers. This information can be accessed through the National Library of Medicine at:

http://dailymed.nlm.nih.gov

COMMENT

None of the ten drugs listed on the site when HTB went to press were HIV-related. Although the EMEA website contains product information in all European languages it is cumbersome and difficult to use. A Similar approach in Europe would therefore be welcomed.

Source: Food and Drug Administration list serve

Steve worked with Jamaica AIDS Support since 1997, and represented the interests of marginalized people and people living with HIV/AIDS in Jamaica and throughout the region. As coordinator of targeted interventions for Jamaica AIDS Support, he had been responsible for ensuring that the most marginalized of Jamaicans—gay, lesbian, bisexual and transgender individuals; sex workers; prisoners—were provided access to HIV/AIDS information and services. By mid 2005, he was chosen as LACCASO’s (Latin America and Caribbean Council of AIDS Service Organizations), in-country project coordinator for Jamaica. His capacity, dedication and courage signaled the way for the most successful implementation of our Advocacy Project.

“Steve Harvey was a person of extraordinary bravery and integrity, who worked tirelessly to ensure that some of Jamaica’s most marginalized people had the tools and information to protect themselves from HIV/AIDS,” said Rebecca Schleifer, researcher with the HIV/AIDS and Human Rights Program at Human Rights Watch and author of a recent report on anti-gay violence and HIV/AIDS in Jamaica.

Considering the enormous loss Steve’s death means for all of us, we request your solidarity, to condemn this brutal crime and request to bring the perpetrators to justice.

Please sign on and send letters of support to:

laccaso-sr@accsi.org.ve

See also:

Christian Aid Report.

http://www.christianaid.org.uk/news/stories/051201s3.htm

Human Rights Watch

http://hrw.org/reports/2004/jamaica1104/

Serono agreed to pay a total of $704,000,000 to resolve the criminal charges and civil liabilities in connection with the several illegal schemes to promote, market and sell Serostim. This global resolution is the third largest health care fraud recovery by the United States.

This included a $136,935,000 criminal fine and $567,065,000 to settle civil liabilities. This global resolution ensures that the federal Medicaid program and each of the State Medicaid agencies who paid any claims for Serostim during the time frame of the investigation, 1996 through 2004, will recoup every dollar paid.

Serono pleaded guilty to introduce on the market bioelectrical impedance analysis (“BIA”) computer software packages for use in calculating body cell mass and diagnosing AIDS wasting prior to FDA approval, which would increase the market for Serostim. They also pleaded guilty to a second Conspiracy of paying illegal renumeration to doctors from March 1999, through December 1999. Ten physicians were offered an all expenses paid trip to a medical conference in Cannes in return for writing up to 30 new prescriptions of Serostim. The value of 30 scripts to be written by each doctor was $630,000, with a total value of approximately $6.3 million in sales.

Source: PRN Newswire and U.S. Attorney

The Communication focuses on key issues such as the involvement of civil society: fostering dialogue with stakeholders such as patients, NGOs and the private sector is central to boosting the impact of any HIV/AIDS strategy. A stronger focus on prevention is also necessary, as contrary to some perceptions the epidemic is on the increase in Europe and basic messages on prevention need to be restated, especially among high risk groups and young people. The Communication also addresses issues including surveillance, treatment and research and details concrete projects in an Action Plan for the period 2006-09.

Involving civil society

The Commission will foster dialogue with HIV/AIDS patients and NGOs, and invite business organisation such as European Union of Industrial and Employers’ Confederations (UNICE) and other corporate players to strengthen their response to the epidemic and play a key role in implementing the EU strategy against HIV/AIDS.

Surveillance

The Commission, in co-operation with Member States, neighbouring countries and the European Centre for Disease Prevention and Control (ECDC), will support collection and processing of data on the epidemic, to help create an integrated surveillance system with full geographic coverage, with estimates of HIV incidence in Europe, and “sentinel surveillance” for high-risk groups.

Prevention of new HIV infections

The Commission will promote prevention programmes, especially for most vulnerable populations, with a priority for safe sex and a specific focus on young people and mother-to-child transmission. It will address transmission risks linked to drug abuse, and promote education, including training for health care professionals.

Counselling, testing, treatment, care and support

The Commission will promote access to health services such as antiretroviral therapies, and voluntary counselling and testing, to help reduce stigma and social exclusion, and monitor the possible development of drug-resistant strains.

Research

The Commission is committed to boosting its research funding for HIV/AIDS, in particular in the area of vaccines and microbicides, and affordable therapeutics and diagnostics.

Neighbouring countries

These include regions, such as the Russian Federation, where the epidemic is widespread and growing. It also covers countries such as Belarus, Moldova, Ukraine, Morocco, and Jordan. The Commission will invite those countries to discuss how to deal with the epidemic in a co-ordinated way through the HIV/AIDS think tank and Civil Society Forum.

The Action Plan annexed to the Communication identifies projects for each priority area. They focus on exchange of best practices, training and awareness-raising programmes

An article in the BMJ documents how drug companies earn back all their research and development (R&D) expenses each year in the research-oriented countries. This means that HIV/AIDS drugs and others can be priced to developing countries at manufacturing cost plus profits. Such prices are typically 5-10% of wholesale prices in the West. Another implication of the article is that the international patent protections that raise prices and extended high prices in countries that sign a U.S. Free Trade Agreement are unwarranted, because the rationale is (again) that pharmaceutical companies do not earn back their R&D costs at European prices and therefore must force higher prices through FTAs like the Central American FTA.

A forthcoming analysis will show that most of the funds worldwide for research to discover new drugs come from the public, not from industry. This has significant implications for policies on patents and setting priorities for research.” writes Donald Light, dlight@princeton.edu.

Ref: Light DW, Lexchin J. Foreign free riders and the high price of US medicines. BMJ 2005;331:958-960 (22 October 2005)

“HIV drug prices are getting higher and higher. This threatens to cause European HIV patients serious difficulties accessing their medication in the near future,” said David Haerry, one of the chairs of the European Community Advisory Board, a working group of EATG.

“This has been a trend since the early days of HIV treatment, but it has accelerated in the last couple of years; nowadays it seems unstoppable.”

His comments followed the announcement by drug company Boehringer Ingelheim that tipranavir (Aptivus), its recently registered protease inhibitor, will cost up to 24 euros a day in Europe – though adding in the other drugs needed for this compound to be effective will at least triple that price.

Introducing new drugs into HIV treatment must be a cost-effective use of national health budgets. The new drugs should be more effective, work against drug-resistant virus and have fewer side effects that need managing.

However the new drugs are also more expensive, and with the number of people living with HIV in Europe likely to continue rising for the foreseeable future, their cost to national health systems threatens to become unsustainable.

Aptivus is the latest in a series. Efavirenz (Sustiva/Stocrin) from BMS/Merck, tenofovir (Viread) from Gilead, lpinavir/r (Kaletra) from Abbott, T-20 (enfuvirtide, Fuzeon) from Roche and atazanavir (Reyataz) from BMS – each of them previously set a new price record in its class when it was licensed. The HIV drug bill is increasing as more Europeans with HIV are living longer.

“Unless there is a fair drug price policy for all disease areas, including HIV, national health systems are going to bear an excessive burden”, explained Wim Vandevelde, a member of EATG’s Board of Directors.

“This case is not hypothetical: EU countries such as Belgium or regions like the Basque Country in Spain are already restricting access to HIV medication for reasons of cost.”

EATG Board member Smiljka Malesevic comes from Serbia. She said: “Even if these drugs are licensed in Central and Eastern Europe, they are completely unaffordable for the vast majority of patients in the part of the world currently experiencing the fastest-growing epidemic. This threatens lives at a time these new drugs should be saving them.”

The scaling up of HIV drug prices is leading local reimbursement authorities to question the entire licensing system and the value and authority of the European Medicine Evaluation Agency (EMEA). This is contributing further to an already fragmented picture of access to HIV drugs. What is happening is against the spirit of the European Union, says the EATG.

Nikos Dedes, Chairperson of the EATG, concluded: “We call all stakeholders –companies, regulatory agencies, governments and patient groups – to treat this issue with urgency. We must collaborate on a serious policy for a sustainable HIV drug pricing system in Europe. This is a duty we owe to people living with HIV and to our society.”

For more info, please contact Joan Tallada, EATG, External Communications Officer (English, Spanish, French, Italian) on + 34 637 464 803 or at joan@eatg.org

Source: EATG Press release, November 2005.

EATG : European AIDS Treatment Group

http://www.eatg.org

The event will develop a core team of proactive patient and consumer partners who are, or wish to become, champions in advancing patient safety in their region. Selected participants will have their accommodation and travel expenses covered.

World Health Organization Patients for Patient Safety
http://www.who.int/patientsafety/patients_for_patient/p4ps_workshop/en/print.html

A review article published in the 15 September edition of Clinical Infectious Diseases has outlined the benefits of buprenorphine (Subutex) in the treatment of intravenous drug use. The drug, which was added to the World Health Organization’s (WHO’s) list of essential drugs in July 2005, may be beneficial in reducing HIV transmission through injecting practices, as well as treating HIV-infected drug users.

Injecting drug use is a major factor in the transmission of HIV internationally, and is linked to the majority of HIV transmissions in central and Eastern Europe and Southeast Asia.

The most commonly used treatment for addiction to opioids, such as heroin and morphine, is replacement therapy with methadone. This drug mimics the effects of opioids by binding to the same receptor molecules as these drugs. These receptors, called mu-opioid receptors, are found on the surface of cells in the brain and spinal cord and trigger the drugs’ sedating, euphoric and pain-killing effects.

Methadone works by preventing the withdrawal symptoms and craving brought about when an addict stops injecting drugs. By reducing the frequency of drug injection, it has been shown to reduce the incidence of HIV infection. However, the use of methadone has a number of problems, including being itself addictive, and its risk of causing breathing problems and overdose. It also interacts with many HIV drugs.

Buprenorphine, in contrast to methadone, is a partial agonist of the mu-opioid receptor. This means that it activates mu-opioid receptors less strongly than methadone, which, the authors argue, may reduce the likelihood of it being abused, particularly in regions where it is supplied in combination with naloxone, a drug that blocks mu-opioid receptors. It is also very difficult to overdose on buprenorphine as its effects plateau at high doses, and it has fewer interactions with HIV drugs, so is easier to use in patients taking antiretroviral therapy.

“The introduction of buprenorphine, a new medication to treat opioid dependence that has fewer restrictions than methadone, holds promise for reducing HIV transmission and improving the care of patients with opioid dependence and HIV disease,” write the review’s authors, Lynn Sullivan and David Fiellin from Yale University School of Medicine. “Methadone has a long history of proven efficacy and benefits in treating opioid dependence, and the addition of buprenorphine serves to expand the treatment options”.

Buprenorphine has become more widely available over the last ten years. It is taken as a tablet dissolved under the tongue daily or three times a week, and was recently added to the WHO’s list of essential drugs. This lists all medicines that should be available in adequate amounts and at an affordable price within all health systems, and are selected according to public health relevance, efficacy, safety and cost-effectiveness.

In their review, the authors summarise the results of cost-effectiveness studies comparing buprenorphine to methadone. They have concluded that buprenorphine treatment programmes may be preferable, both in the treatment of opioid dependence itself, and in its effects on reducing new HIV infections.

However, despite the drug’s benefits, the authors point out that few studies have examined its effects on HIV risk behaviour, such as needle sharing and unsafe sex, although larger scale studies are planned.

In injection drug users (IDUs) who are already HIV-positive, there is evidence from the French Manif 2000 cohort study that use of buprenorphine improves adherence to antiretroviral drugs. Although this was not associated with a better response to HIV therapy, and over half of the patients reverted to IV drug use during the study, they pointed out that, despite limited evidence, buprenorphine is less likely to interact with HIV drugs than methadone.

AZT (zidovudine, Retrovir) and some protease inhibitors may increase buprenorphine levels, but the pharmacological properties of buprenorphine mean that its effects are not increased above a ‘ceiling’ level, so increased buprenorphine levels are unlikely to cause dangerous side-effects. However, the authors write, “as efforts continue with the goal to integrate use of buprenorphine into HIV care, further studies will need to be undertaken to make more than theoretical statements about these interactions.”

In conclusion, there is room for substantial optimism about the inclusion of buprenorphine in the treatment of IDUs for the prevention of HIV transmission and the treatment of IDUs who are already HIV-positive. Although the practicalities of treatment programmes remain to be fully evaluated, many of the questions surrounding the drug’s role will be answered in ongoing and future studies.

“In the meantime, office-based clinicians, for the first time in nearly 100 years, have the opportunity to provide a unique treatment to minimise the adverse impact of opioid dependence,” the authors conclude.

Source:

http://www.aidsmap.com

Ref:

Sullivan LE et al. Buprenorphine: its role in preventing HIV transmission and improving the care of HIV-infected patients with opioid dependence. Clin Infect Dis 41: 891-896, 2005.

The UNAIDS funded report, Criminalisation of HIV transmission in Europe, comes at a critical time, amid media hype surrounding HIV transmission cases in the UK, the Netherlands, Sweden and Finland.

The report identifies and analyses the laws used in relation to HIV transmission and maps prosecution within signatory States of the European Convention of Human Rights. It also discusses the value and appropriateness of the use of criminal law and other punitive measures in the response to the epidemic.

Until recently the majority opinion seemed to be that criminal law should only be used in the context of HIV as a last resort, for example in cases of rape or wilful deception.

Many different types of law are used to prosecute transmission of HIV, including HIV-specific laws and general criminal law provisions. Some laws require intent, some do not. Some laws criminalise only actual transmission, while others criminalise the risk of transmission. Furthermore, some laws include “reckless” as well as “negligent” behaviour in addition to “intentional” behaviour in their legal provisions.

Though data on the background of people prosecuted was hard to find, it appears that a substantial number are from marginalised groups, in particular migrants. Men appear more likely to be prosecuted than women and there have been no traceable convictions for transmission from mother to baby.

Lisa Power, Head of Policy at Terrence Higgins Trust said: “We urge lawmakers to take an informed approach based on human rights and public health if they wish to bring the law to bear on HIV transmission. “Criminalising consensual sexual acts will discourage people with HIV from seeking help in maintaining safer sex and drive such behaviour underground. Positive support to maintain safer sex is a basic part of preventing onward transmission.”

The full report, ‘Criminalisation of HIV transmission in Europe’ can be downloaded at

Global Network of People Living with HIV/AIDS
http://www.gnpplus.net

and

Terrence Higgins Trust
http://www.tht.org.uk

Previous immigration policy

Canadian immigration law provided that a person may be denied a visa or entry to the country as “medically inadmissible” if:

a) they are “likely to be a danger to public health or public safety”; or b) they “might reasonably be expected to cause excessive demand on health or social services” – and specifically, if they would add to waiting lists for services and thereby add to morbidity or mortality as a result of denial or delay of these services for Canadian citizens or permanent residents.

Generally, neither of these grounds applies to a person living with HIV/AIDS seeking to enter the country as a visitor on a short-term basis (i.e., under 6 months).

• HIV is not a casually communicable infectious disease (unlike tuberculosis). It is Canadian government policy that people living with HIV/AIDS do not represent a danger to public health or safety by virtue of their HIV status.
• Similarly, Canadian policy states that a person living with HIV/AIDS entering the country on a short-term basis “would not normally be expected to place a demand on health services”.

Canada has now amended its application form for a “temporary resident visa” to change the health-related questions posed to visa applicants. In May 2005, the new visa application form was implemented by CIC.

As a result of the recent change, Canada does not require people applying for a visa to enter Canada as a short-term visitor to disclose known HIV infection on the visa application form.

For more information:

Canadian HIV/AIDS Legal Network’s website

http://www.aidslaw.ca/

Source: healthdev.org

COMMENT

This positive approach to allow HIV-positive individuals the right to travel could easily be adopted by the USA which still maintains a discriminatory policy that includes HIV as a barrier to enter the country. This is why IAS conferences are no longer held in the USA.

Current US policy does not include either visiting family or vacation as a reason to grant a visa for an HIV-positive person. Advice for HIV-positive individuals to apply for a visa for these reasons will not help them visit the US.

Data presented at the 2005 National HIV Prevention Conference in Atlanta, Georgia, indicate that roughly one million Americans were living with HIV at the end of 2003 and that HIV prevalence remains extremely high among African-American men who have sex with men (MSM) in several U.S. cities. Other data show that while HIV diagnoses reported among adolescent and young adult females have declined steadily, diagnoses in males have increased in recent years. Data presented also show that some prevention programs are substantially reducing sexual risk behavior among people with HIV and those at risk for infection, and that voluntary rapid testing efforts are increasing the number of people who find out their HIV status.

African Americans and MSM Most Affected

New Centers for Disease Control and Prevention (CDC) estimates of HIV prevalence in the United States indicate that between 1,039,000 and 1,185,000 people were living with HIV in December 2003. The estimates provide the clearest picture to date of the scope of the U.S. epidemic overall and among specific racial and ethnic and risk groups.

The new estimates indicate that HIV continues to have the greatest impact among African Americans and MSM. At the end of 2003, blacks accounted for 47 percent of people estimated to be living with HIV in the US; whites accounted for 34 percent and Hispanics for 17 percent. Asian/Pacific Islanders and American Indians/Alaska Natives each represented roughly 1 percent of the HIV-positive population. By transmission category, MSM remained the most heavily affected group, accounting for 45 percent of people living with HIV. Individuals infected through high-risk heterosexual contact comprised 27 percent, and those infected through injection drug use accounted for 22 percent of the HIV-positive population. Roughly three-quarters (74%) of Americans estimated to be living with HIV are male.

A separate CDC analysis suggests that undiagnosed HIV infection continues to play a significant role in the extremely high rates of infection among African-American MSM. Consistent with earlier research, black MSM in a new five-city study were more than twice as likely to be infected with HIV as other MSM, and were less likely to be aware of their infection. Forty-six percent of black MSM in the study were HIV-positive, compared to 21 percent of white MSM and 17 percent of Hispanic MSM. Among HIV-infected MSM, 67 percent of black men, 48 percent of Hispanic men, and 18 percent of white men were unaware of their infection before study participation, underscoring the need to reach MSM with testing and prevention services. The study surveyed 1,767 MSM over age 18 at public venues in Baltimore, Los Angeles, Miami, New York City, and San Francisco between June 2004 and April 2005 (Plenary session, “New Approaches to Tracking the HIV Epidemic in the U.S.”).

Other CDC data point to the continuing impact of HIV on young African-American MSM across the nation. Researchers examined trends in new HIV diagnoses (with or without AIDS) among persons 13 to 24 years of age between 1994 and 2003 in 25 U.S. states with longstanding, name-based HIV reporting . Results indicate that new diagnoses declined significantly among young women, but rose among young men. Among 13- to 24-year-old females, new HIV diagnoses fell 20 percent over the 10-year period. HIV diagnoses also declined among young men for the first few years of the period (by 30% from 1994 to 1998); but the decline was offset by a 41 percent increase from 1999 to 2003. The increase among young men was driven by a 47 percent rise in diagnoses among MSM ages 20-24, 60 percent of whom were black. While researchers were unable to determine if the increases in HIV diagnoses among young men were the result of increased testing or an actual increase in new infections, the findings are consistent with other recent data suggesting a possible resurgence of HIV among young MSM.

Source: CDC Press Release 13 June 2005

BMJ early online have published a case review of new HIV diagnoses in the UK and Ireland, looking at the occurrence of late diagnosis and associated features and to determine if patients had prior presentations that may have been related to HIV infection.

Data was collected via questionnaires, which were sent to adult HIV care providers in the UK and Ireland. Data on a total of 977 patients presenting with new diagnosis of HIV infection in January-March 2003 was collected.

A total of 301 patients (33%) presented late – this was more common in both older patients (adjusted odds ratio per increase in age group 1.68, 95% CI 1.42-1.98, p=0.0001) and in black Africans (1.66, 1.05-2.62, p=0.03). Overall, 401 (41%) were diagnosed via routine screening (e.g. sexual health, genitourinary or HIV clinic) – diagnosis in this way was associated with a lower chance of late diagnosis. A high proportion of patients (17%) sought medical care with symptoms in the preceeding 12 months but remained undiagnosed.

The authors conclude that this study provides further evidence of the late diagnosis of HIV infection, following national trends reported by the Health Protection Agency. They say that improving the offering and uptake of HIV testing both as part of routine screening and as indicated by associated medical conditions should reduce the number of undiagnosed infections.

Electronic BMJ (British Medical Journal)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38398.590602.E0v1

Results of the analysis showed that from 1997 through 2002, syphilis diagnoses (primary, secondary and early latent) were up by 213 percent in heterosexual males, 1,412 percent in men who have sex with men (MSM), and 22 percent in females. A series of outbreaks have driven the increases through October 2003, chiefly in Manchester (528 cases) and London (1,222 cases). The majority of cases were MSM, and all the outbreaks were geographically localized. HIV co-infection was reported in a high percentage of cases. Oral sex was often reported as a route of transmission.

“Syphilis has re-emerged in response to behavior change, probably driven by changes in the HIV epidemic,” the authors concluded. “The future course of the epidemic is difficult to predict and control remains elusive.”

Source: CDC HIV/STD/TB Prevention News Update. April 11, 2005

Ref: Simms I, Fenton KA, Ashton M et al. The re-emergence of syphilis in the United Kingdom: the new epidemic phases. Sex Tran Dis 32(4) 220-226 (04.05.05)

The study involved treatment resistant heroin addicts taking part in methadone maintenance programmes in six cities in the Netherlands. Prior to study entry, the heroin addicts frequently engaged in illegal activities to acquire money or drugs.

They were randomised to treatment with methadone plus heroin (experimental group) or with methadone alone (control group). After one year, data from 430 patients were analysed.

Co-prescription of heroin was associated with better quality of life measures. Although the costs of co-prescription were considerably higher, they were offset by lower costs of law enforcement and reduced costs of crime against property. The average total net savings amounted to 12,793 per patient per year.

From a societal perspective, supervised medical prescription of methadone plus heroin to chronic, treatment resistant addicts is very efficient.

Source: BMJ online

Ref: Cost utility analysis of co-prescribed heroin compared with methadone maintenance treatment in heroin addicts in two randomised controlled trials.
http://bmj.com/cgi/content/full/330/7503/1297

The rate of HIV transmissions in heterosexual sex was highest during early-stage infection, in a retrospective study of 235 monogamous, HIV discordant couples in a Ugandan population-based cohort. [1] Observers are already pointing to the study as evidence for the need for new approaches to HIV prevention strategies and the authors themselves conclude that their findings have implications for HIV prevention and for projecting the effects of antiretroviral treatment on HIV transmission.

The US-Ugandan study enrolled 15,127 adults into a community randomised trial of STD control for AIDS Prevention in the Rakai district of Uganda. Wawer and colleagues retrospectively identified 235 monogamous HIV discordant couples and estimated rates of transmission per coital act by the index partner’s stage of infection – recent seroconversion, prevalent or late-stage infection – and the adjusted rate ratio of transmission per coital act was estimated by multivariate Poisson regression.

After serocinversion of the index partner, the rate of transmission (0.0082 per coital act) within the first 2.5 months was almost 12-fold higher than that observed in the prevalent index couples (0.0007 per coital act). The rate increased significantly again at about two years before the index partner’s death.

The overall rate of transmission observed in these couples is consistent with previous estimates from Rakai, Europe and North America, but this analysis provides the first empirical data on the substantial variation in transmission by stage of infection.

The data were collected from stable, heterosexual couples, whose primary risk was through vaginal intercourse, and additional studies are required to examine transmission by stage of infection in other epidemic settings. “Nonetheless, our data have a number of clinical and epidemiological implications,” write the authors

The highest rate of transmission per coital act and the highest proportion of transmissions occurred at a time when few seroconverters know their HIV status or receive antiretroviral treatment. “Thus,” write Wawer and colleagues, “ART, initiated relatively late during infection, under current guidelines, may have only a modest impact on HIV transmission. Also, because most HIV transmissions occur before index cases are eligible to receive ART, the heterosexuals spread of drug-resistant HIV may be modest in this population. Measures that prevent primary HIV infection or reduce early viraemia (as may occur with HIV vaccines) are likely to have a greater effect than ART on the spread of HIV.”

They also draw attention to the advantages of increasing efforts to identify people with early-stage infection in order to promote safer behaviour and to consider the provision of treatment.

An editorial commentary in the Journal of Infectious Diseases says: “Wawer et al have confirmed the remarkable threat of HIV transmission posed by people with newly acquired HIV infection. The challenge now is to waste no time in finding the most creative strategies to incorporate these results into global HIV prevention efforts.” [2]

Both the editorial commentary and the full article are available on-line as free articles.

COMMENT

The point of including this article was not to suggest that antiretrovirals should be used to slow down transmission on an epidemiologically relevant level. Condoms are still the best and most and cost effective approach with any stage of HIV-infection; the primary focus of antiretrovirals is always to treat HIV-positive patients for their own healthcare.

It does however provide important data to support what forward thinking clinicians and prevention workers have realised for a long time: that a key driving force behind the epidemic is the behaviour of recently infected, undiagnosed individuals, who consider themselves HIV-negative, and behave as such, while in fact being the most highly infectious group in the population.

Recent behavioural studies – including a study presented at the BHIVA meeting in Dublin – show that receiving an HIV diagnosis leads to more extensive behaviour change towards protecting partners of unknown status than any other intervention. [3]

References:
1. Wawer M, Gray R, Sewankambo N et al. Rates of HIV-1 Transmission per Coital Act, by Stage of HIV-1 Infection, in Rakai, Uganda. The Journal of Infectious Diseases    2005;191:1403-1409
http://www.journals.uchicago.edu/JID/journal/issues/v191n9/33445/33445.html
2. Cohen M and Pilcher C. Editorial Commentary: Amplified HIV Transmission and New Approaches to HIV Prevention. The Journal of Infectious Diseases    2005;191:1391-1393
http://www.journals.uchicago.edu/JID/journal/issues/v191n9/34190/34190.html
3. Fox J, McClure M, Weber J et al. Risk factors for the acquisition of HIV in individuals known to have recently seroconverted. 11th BHIVA Conference, 20-23 April 2005, Dublin. Oral abstract O15.

Although Orange previously had a policy that they did not charge contract customers to call any freephone number, pay as you go customers still faced hefty charges for calling freephones – and that included charity helplines. Orange has now confirmed that although contract customers will in future be charged to call commercial freephone numbers, all of its customers will now be able to call any freephone helpline that is a member of the THA and their call will not be charged nor itemised.

The i-Base phone number is on 0808 800 6013 and can offer information in English or French, usually provided by positive treatment advocates, and is open Mondays, Tuesdays and Wednesdays from noon to 4pm.

I am writing to you to request your assistance in recruiting volunteer physicians and nurses to improve the capacity for providing care to HIV-infected patients in developing countries.

ICEHA is a non profit organisation of physicians and nurses who volunteer their expertise on HIV care and infectious diseases to clinics in developing countries. ICEHA’s volunteers equip local healthcare professionals with the skills needed to take care of their own patients and enable developing countries to fight the HIV epidemic from within. ICEHA is always in need of new healthcare providers to volunteer in our programmes overseas.

As part of an effort to recruit more volunteers, we are contacting reputable publications that cater to healthcare providers to see if they can help get the message of these volunteer opportunities out to potential volunteers.

More information about ICEHA is available on our website:

http://www.iceha.org

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by the L1-L3 serovars of the obligate intracellular bacterium Chlamydia trachomatis. These particular strains of chlamydia are more virulent and tend to produce more invasive disease in humans. Chlamydial serovars A-K, which are largely confined to infecting columnar epithelial surfaces of the genital tract and the eye are far more prevalent than the LGV serovars which predominantly infect monocytes and macrophages, passing through epithelial surfaces to regional lymph nodes usually resulting in disseminated infection.

LGV, which was relatively common in industrialised countries until the advent of broad-spectrum antibiotics in the first half of the twentieth century, has become a rare disease, while remaining endemic in parts of Africa, Asia, South America and the Caribbean. Clinically it is difficult to distinguish from other causes of genital ulcer disease – especially those associated with “bubo” formation (large, swollen lymph nodes), such as chancroid. However, there has recently been a resurgence of its appearance in the western world, with subtle changes in its mode of presentation. It is estimated that LGV accounts for between 10 and 20% of genital ulcer disease in parts of the world where it is endemic, with chancroid, syphilis and herpes simplex infection being far more common. Indeed, 10% of patients presenting with buboes to a clinic in Bangkok were found to have LGV, with a large epidemic recently reported among crack cocaine users in the Bahamas. [1-3]

Clinical features

Classically the clinical course has been divided into three stages: The primary stage involves the site of inoculation, the secondary stage the regional lymph nodes and occasionally the anorectum, with the tertiary stage comprising late sequelae affecting the genitals or rectum.

The primary stage occurs after an incubation period of 3-30 days with the formation of a small painless papule, which may ulcerate occurring at the site of inoculation. This primary lesion is virtually always self-limiting and may not always occur and in most cases passes unnoticed by the patient.

The secondary stage occurs some weeks after the primary lesion and can take one of two forms:

(1) The inguinal form – commoner in men since the lymphatic drainage of the vagina and cervix is to the retroperitoneal rather the inguinal lymph nodes. Its cardinal feature is the presence of painful inguinal and/or femoral lymphadenopathy, which is usually uniltateral. Adenopathy above and below the inguinal ligament is termed the ‘groove sign’ and was once thought to be pathognomonic of LGV. The lymph nodes are usually firm and necrotic. The necrotic areas may enlarge and coalesce to form stellate abscesses, which eventually break down to form discharging sinuses, although this is relatively uncommon and more a feature of chancroid.

(2) The ano-rectal form – classically more common in women; and in men who have sex with men (MSM) who practise receptive anal intercourse. It usually presents as a haemorrhagic proctitis. Patients present with bleeding per rectum and pronounced proctalgia, often associated with systemic features – pyrexia, chills and weight loss. Proctoscopy reveals a granular or ulcerative proctitis (similar to ulcerative colitis), which is nearly always confined to the distal 10cm of the ano-rectal canal (4). Extragenital lymphadenopathy has also been described.

The tertiary stage occurs usually as the result of chronic untreated LGV: fibrosis leads to lymphatic obstruction causing elephantiasis of the genitals in either sex with rectal involvement leading to the formation of strictures and fistulae. This often leads to surgical correction of the problem, which can often be severe and debilitating. The tertiary stage occurs far more commonly in women giving rise to a syndrome known as esthiomene (Greek = “eating away”), with widespread destruction of the external genitalia.

Diagnosis

The differential diagnosis of sexually acquired genital ulceration includes chancroid, herpes simplex, syphilis and donovanosis (granuloma inguinale). Less commonly this may arise as a result of trauma, non-sexually transmissible infections e.g. cutaneous leishmaniasis and a fixed drug eruption. The differential diagnosis of inguinal adenopathy includes chancroid, herpes and syphilis although a genital ulcer usually precedes lymphadenopathy in these cases. More generalised lymphadenopthy has a wider differential including lymphoma and HIV.

Laboratory diagnosis of LGV largely depends on serological tests which are genus specific and do not distinguish between infection with other chlamydial species. However, since LGV is far more invasive than other members of the genus it usually leads to higher titres of serum immunoglobulins than uncomplicated infections of C trachomatis serovars D-K. A titre of > 1:256 strongly supports the diagnosis while a titre of <1:32 virtually rules it out except in the very early stages of infection. The microimmunofluorescence (MIF) test can distinguish between infection by different chlamydial species but is not widely used in clinical practice. However, a MIF IgG titre of > 1:128 strongly suggests LGV although invasive genital infection by serovars D-K (eg pelvic inflammatory disease) can also give rise to high titres of anti-chlamydial antibody.

Further identification of the organism can be achieved by aspirating bubo fluid or in ulcer material and isolating C Trachomatis in tissue culture. This technique is also not widely available. In contrast to diagnosing infection with serovars D-K by commercially available enzyme immuno-assays (EIAs), which are used extensively to diagnose urethral and cervical infection, this form of diagnosis has not been widely evaluated for LGV. Similarly, DNA amplification assays (PCR or LCR) which detect Chlamydia specific genomic or plasmid DNA have also not been widely evaluated for the detection of LGV – although PCR was used extensively to diagnose LGV in samples taken from ulcer samples in the Bahamas.

The detection of C Trachomatis in bubo material by any of these methods strongly supports the diagnosis of LGV while detection of the organism in ulcer material only supports the diagnosis if it can be shown to be an LGV strain by DNA sequencing or typing with a monoclonal antibody – methods which by and large are not routinely available in day to day practice.

Management

Recommended treatment for both bubonic and anogenital LGV is doxycycline 100mg twice daily for at least 21 days. In pregnant women or persons otherwise intolerant of tetracyclines a macrolide antibiotic such as erythromycin 500mg four times daily, also for 21 days should be employed. Azithromycin is also likely to be effective against LGV although the exact duration of treatment has not been correctly determined; one suggested course would be 1g daily for 10-14 days.

LGV in the 21st Century

Since December 2003 a worrying number of outbreaks of LGV have been reported in European and North American cities. These appear to be largely confined to HIV positive MSM and most appear to be caused by the L2 genotype. Most cases present with a haemorrhagic proctitis and are confined largely to men of white ethnicity. High levels of concurrent sexually transmitted infections (Gonorrhoea, syphilis, HSV and hepatitis B virus) were also seen. Transmission of Hepatitis C virus (HCV) has been associated with the LGV outbreak in Rotterdam in the Netherlands. Contact tracing has largely proven to be a futile exercise as most of the infected men reported numerous anonymous sexual encounters with high levels of unprotected anal intercourse and other high risk practices such as fisting (which itself is strongly associated with the sexual transmission of HCV) and sharing of sex toys.

In response to these outbreaks the Health Protection Agency for England initiated enhanced surveillance measures for LGV. These were established in October 2004 after several sexual health clinics (predominantly in London) reported increased numbers of cases of bloody proctitis. Clusters of LGV have so far been identified in Rotterdam (>92 cases), Antwerp (27 cases), Paris (38 cases) and confirmed cases in Stockholm and Hamburg in addition to sporadic cases in New York, San Francisco and Atlanta in the USA. These outbreaks appear to be concentrated in sexual networks of gay men and appear to be associated with sex parties that have attracted men from across Europe.

The HPA sent out an alert to GUM clinics in England and established a case definition, reference service and reporting system for LGV. [5] The case definition used by the HPA is confirmation of C Trachomatis and presence of LGV serovars – L1, L2 or L3 by genotyping. The HPA reference service tests rectal specimens from patients with ano-rectal symptoms (bloody proctitis, rectal discharge) or urethral specimens from patients with inguinal lymphadenopathy known to be positive for C Trachomatis.

In January 2005, the first 24 cases of LGV were reported in the UK – most from London clinics. Enhanced surveillance data were available for 19 cases and confirmed characteristics similar to other European cities: all were MSM, 17 HIV positive, 4 were also HCV positive and most had symptoms suggestive of LGV.

Up to the middle of February 2005, a total of 34 cases of LGV have been reported in the UK. [6] In addition other anecdotal cases have been reported from other centres in the UK which were not subject to the HPA’s enhanced surveillance (eg in Swansea an HIV positive MSM presented with a haemorrhagic proctitis and high levels of anti-chlamydial antibodies, (>1:256), genotyping was not available but the diagnosis of LGV was made presumptively and he responded to 21 days treatment with doxycycline 100mg bd). [7]

Noteworthy features of the recent outbreaks are that they tend to occur in white MSM, although some patients have reported sexual encounters with men from Africa or Latin America. Furthermore, very few cases of urethral infection have been reported alongside rectal infections, which further confounds the epidemiology of the outbreaks.

Conclusions

The implications are quite clear: All clinicians who deal with HIV positive gay men’s sexual health should be vigilant to the possible presenting symptoms of LGV and wherever possible enrol the assistance of the HPA in establishing a diagnosis. Adequate treatment should be initiated as soon as possible thereby avoiding the potentially serious sequelae of untreated LGV. Ultimately it should not be forgotten that infection with LGV is usually associated with concomitant infection with another STI – this is especially true for HIV, which is propagated far more easily in the presence of genital ulcer disease.

COMMENT

LGV was the focus of presentations at the BHIVA Spring conference in Dublin that stressed the importance of treatment for similar symptoms, even if a diagnosis is not confirmed or available.

Awareness of the additional information and the surveillance system that was established at the end of 2004 by the Health Protection Agency is clearly important for all GU treating physicians.

The HPA website includes useful pages on LGV, including:

HPA enhanced surveillance system for LGV.

LGV home page.

LGV general information.

References

1. Hitun Y et al. Comparison of clinically directed, disease specific and syndromic protocols for the management of genital ulcer disease in Lesotho. Sex Transm Inf 1998 74 (suppl 1) S23-28.
2. Viravan C et al. A prospective clinical and bacteriologic study of inguinal buboes in Thai men. Clin Infect Dis 1996 22, 233-239.
3. Bouwens JE et al. Epidemic LGV during epidemics of crack cocaine use and HIV infection in the Bahamas (in press)
4. Quinn TC et al. Chlamydia trachomatis proctitis N Engl J Med 1984 311 1543-1546.
5. Health Protection Agency. Enhanced surveillance of LGV in England. Commun Dis Rep CDR Wkly [serial online] 2004. 14 (41). News – available at:
http://www.hpa.org.uk/cdr/PDFfiles/2004/cdr4104.pdf
6. Macdonald N et al. Initial results of enhanced surveillance for LGV in England. Eurosurveillance 2005 10 20. January 2005 (available at:
http://www.eurosurveillance.org/ew/2005/050127.asp
7. Personal communication with Dr K. Yoganathan, Consultant GU Physician, Singleton Hospital, Swansea, UK.

The Medical Foundation for AIDS & Sexual Health (MedFASH) has launched a new publication aimed at providing practical advice for the primary healthcare team on HIV.

The booklet, which includes full colour photos, is entitled ‘HIV in primary care – an essential guide to HIV for GPs, practice nurses and other members of the primary healthcare team’. It is in an easy-to-use format and covers the main HIV-related conditions and their symptoms.

The booklet offers practical help on clinical diagnosis and how to raise the subject of testing with patients. Topics include how to offer an HIV test and give results; the side-effects of antiretroviral therapy and how to complement specialist care; primary healthcare for people with HIV; and practice policies and systems to ensure optimal patient care and staff safety.

Free copies can be ordered by GPs and primary healthcare teams from Magnus Nelson at MedFASH on 020 7383 6345 and the booklet will shortly be available to download:

www.medfash.org.uk

Recently they have included ARV and HIV-related OI medications within their programmes including the ARVs nevirapine, lamiduvine, stavudine, efavirenz, indinavir and Combivir; plus fluconazole, aciclovir, valaciclovir, famiclovir and any antibiotics and analgesics. The project is not able to accept morphine-based medicines or dihydrocodeine.

The organization runs a strict quality assurance programme, based on recipient-driven requests. All medication is tracked and protected from commercial gain.

The project is particularly interested in working with doctors or pharmacists who work within HIV care at the moment and are responsible for patient returned medications after a treatment change.

For further details please contact:

InterCare,
46 The Halfcroft,
Syston,
Leicester,
LE7 1LD

Tel: 0116 269 5925
Fax: 0116 269 6825

intercare@webleicester.co.uk

www.intercare.org.uk

It is intended to be an aid for physicians in individualizing treatment doses for patients on therapeutics metabolised through these genes.

COMMENT

This Roche assay only looks at the CYP450 2D6 and 2C19 systems at this time. Although most of the problematic ARVs are metabolized by the 3A4 system, this test might be useful for methadone, some OI treatments and maybe TMC114, which is a sulfonamide.

This useful table gives an indication of the complexity of the CYP450 and the medicines and foods that induce or inhibit individual systems.

www.edhayes.com/CYP450-2.html

Coronary artery bypass graft (CABG) is a feasible and safe procedure in HIV-positive patients, conclude Boccara and colleagues at the French Italian Study on Coronary artery disease in AIDS patients (FRISCA-2). There was no difference in immediate postoperative outcomes between HIV-positive and HIV-negative patients. However. long-term follow-up showed higher rates of major adverse cardiac events (MACE) was significantly higher in HIV-positive patients due to an increased rate of repeat revascularisation procedure (reCABG and percutaneous coronary intervention [PCI]).

From 1997 to 2003 inclusive, researchers compared 22 HIV-positive and 42 HIV-negative control patients matched for age and gender who underwent CABG. They compared baseline characteristics, immediate results and clinical outcome (MACE: death from any cause, myocardial infarction, re-intervention and/or PCI) at 34 months.

Cardiovascular risk factors were nearly identical in both groups with a higher rate of hypercholesterolaemia (96% versus 74%, p=0.045) and hypertriglyceridaemia (82% versus 45%, p=0.005) in HIV-positive patients. Obesity was more frequent in the control group (33% versus 0%, p=0.001).

In the HIV-positive group, mean CD4 count was lower post-operation compared to beforehand (427 +/- 162 vs 503 +/-200 cells/mm³) but this was without clinical significance in the follow-up. Coronary multivessel disease (> 2 vessel disease) was present in nearly all patients (96% HIV-positive and 93% HIV-negative). Left Ventricular Ejection Fraction and mean number of grafts were also similar in the 2 groups (55%+/-10 versus 50%+/-14, respectively.

After one month, the rate of post-operative death, MI, stroke, mediastinitis, and re-intervention was identical in both groups. However, at 34 +/-20 months follow-up, rate of occurrence of first MACE was higher in HIV-positive group. The only predictor of MACE at follow-up was HIV infection itself with a hazard ratio of 6.3 (95%CI 2.2-17.9, p=0.001).

Ref: Boccara F, Cohen A, Odi G et al. Coronary artery bypass graft in HIV-infected patients. A multicentre case control study. 6th Lipodystrophy Workshop (6th IWADRLH), Washington. Abstract 115. Antiviral Therapy 2004; 9:L65.

A research letter in the 24 September edition of AIDS describes a French case of a treatment experienced pregnant woman with virological breakthrough treated with enfuvirtide during the last three weeks of her pregnancy.

The 38 year old HIV positive woman became pregnant in January 2003 while receiving an antiretroviral regimen of 3TC, tenofovir and lopinavir/ritonavir (Kaletra). Her CD4 count was 365cells/mm³ and she had a viral load of 40,522 copies/mL.

The patient was diagnosed in 1990 and treated with zidovudine monotherapy in 1994 (her lowest CD4 cell count of 25 cells/mm³ was recorded in May 1995) to which 3TC was added in 1995, and indinavir in 1996.

Her CD4 cell count was stable at 300 cells/mm³ on this regimen, but her viral load remained detectable. Her treatment was changed to d4T, ddI, ritonavir, and saquinavir (Invirase) in 1997 and switched again to d4T, 3TC and efavirenz in 1999 due to lipodystrophy. In August 2001, after virological breakthrough she was again switched to another regimen of 3TC, tenofovir and lopinavir/ritonavir. She became pregnant on this regimen.

She received a genotype resistance test in August 2003, at which time her viral load was 32,961 copies/mL. The test results found her to be resistant to both nucleoside reverse transcriptase inhibitors and protease inhibitors but sensitive to non nucleoside reverse transcriptase inhibitors. Mutations were found at M41L, E44D, D67N, M184V, L210W and T215Y, indicating resistance to AZT, 3TC, ddI, d4T and abacavir and possible resistance to tenofovir. And at L10F, K20R, M36I, M46L, I54V, L63P, A71V, V82A, I84V and L90M, conferring resistance to all protease inhibitors.

Enfuvirtide and nevirapine were added to her regimen of 3TC, tenofovir and lopinavir/ritonavir three weeks before an elective Caesarean section was performed, and on 10 September 2003 she gave birth to a healthy baby girl.

The neonate was treated at birth with AZT, 3TC and nevirapine, and was PCR negative at day 3, and 1, 3 and 6 months. At the time of delivery, the mother’s viral load was 57 copies/mL and her CD4 cell count was 549 cells/mm³ (16.8%).

The investigators write: “This is the first reported use of enfuvirtide during pregnancy in a patient with virological breakthrough. The HIV viral load was reduced to less than 400 copies/mL at the time of delivery, with no adverse effects in the mother or in the child (up to age 6 months). Despite the very limited experience with enfuvirtide in pregnancy, this case shows the potential value of this fusion inhibitor in preventing maternofoetal HIV transmission.”

comment

The first report of T-20 in pregnancy confirms that the introduction of two classes of therapy to which HIV is sensitive effectively reduces viral load. This is known to be associated with a reduced risk of transmission.

Treatment appears to have been deferred to late in pregnancy to minimise the risk of further virological rebound before delivery. Little comment can be made on the safety of T-20 in this setting.

Ref: Meyohasa MC, Lacombea K, Carbonneb, B, et al. Enfuvitide prescription at the end of pregnancy to a multi-treated HIV-infected woman with virological breakthrough. AIDS 2004, Vol 18 No 14. Research letters 1966.

In the current study, the authors surveyed lead clinicians working in genitourinary medicine clinics about their experiences and opinions of the dispersal of HIV-positive asylum seekers. Centres that do not treat HIV-positive patients were excluded. In December 2003, anonymous questionnaires were sent to doctors asking about the appropriateness of dispersal in 10 clinical scenarios and about perceived barriers to effective dispersal.

Fifty-six of 75 eligible centres returned questionnaires; 34 of these were outside London, and 20 had had an HIV-positive asylum seeker dispersed to them. A total of 13 centres reported patients dispersed both to and from them.

Of the 56 returned questionnaires, frequentlybarriers to successful dispersal were dispersal at short notice (37) or with no prior arrangement (43). Just three centres had experienced appropriate transfer of care. Additional barriers cited included lack of community support (41), low staffing levels in the receiving centre (40), and lack of facilities to support vulnerable asylum seekers with psychological problems (43).

Some doctors spontaneously listed negative consequences attributed to dispersal, although the questionnaire did not inquire about such. Problems relating to unintentional interruption of antiretroviral therapy (4), mother-to-child HIV transmission (3), and HIV-related death (2) were reported. Many of the 56 returned questionnaires said dispersal of HIV-infected asylum seekers was inappropriate in certain situations – during initiation of HIV therapy (47), in patients receiving salvage treatment (43), in those currently undergoing medical investigations (50), where care involved multiple medical specialties (52), and when patients had progressed to AIDS (45).

Of the potential barriers to safe dispersal of HIV-infected asylum seekers, it is of particular concern that dispersal is done at short notice and frequently without appropriate transfer of medical information, the researchers noted. “Inappropriate dispersal of an HIV infected patient could lead to HIV resistance, onward transmission of HIV infection and avoidable morbidity and mortality for the asylum seeker,” the researchers noted. “Before the decision to disperse, the National Asylum Support Service should seek specialist advice and consider the impact on the infrastructure and staffing of the receiving centre,” they concluded.

Source: CDC HIV/STD/TB Prevention News Update, via AEGiS
http://www.aegis.com/channel/s/AD041664.html

Full article available online at bmj.com (free registration required):

Ref: Creighton S, Sethi G, Edwards SG et al. British Medical Journal (08.07.04) Vol. 29; No. 7461: P. 322- 323 – Monday, August 16, 2004.
http://bmj.bmjjournals.com/cgi/content/full/329/7461/322?ecoll

The move is an attempt to maintain a record of trials that find either negative or inconclusive results and which are less likely to be submitted for publication.

All studies need to be registered at or before patient enrollment on a ‘free-to-view’ accessible electronically searchable database that is managed by a not-for-profit organisation.

An acceptable registry must include at minimum the following information: a unique identifying number, a statement of the intervention (or interventions) and comparison (or comparisons) studied, a statement of the study hypothesis, definitions of the primary and secondary outcome measures, eligibility criteria, key trial dates (registration date, anticipated or actual start date, anticipated or actual date of last follow-up, planned or actual date of closure to data entry, and date trial data considered complete), target number of subjects, funding source, and contact information for the principal investigator.

The statement only mentions one currently available database that meets these criteria:

http://www.clinicaltrials.gov

Source: Editorial, NEJM, September 2004

On the night of 9 August at about 10.30pm, 39 members of Blue Diamond Society (BDS), a gay rights and HIV prevention organisation in Nepal, were arrested and taken to Hanuman Dhoka Police Station in the centre of Kathmandu. First reports as HTB went to press said they were being detained without food and had been treated inhumanly. Sunil Pant, Director of BDS issued a statement saying: “We are very concerned. They were arrested along with other people from different occupations and this is against the human rights. The inhuman behaviour by the police is not only in arresting but also brutally beating up the arrested MSMs [men who have sex with men], which is against any principles.

“Thus, we request His Majesty’s Government of Nepal to release our captured members without any conditions. Basically, Blue Diamond Society is involved in purely promoting human rights and HIV awareness among sexual minorities in Nepal without causing harm to anyone, thus we request HMG of Nepal and the other related organisations not to cause any harm which may affect our members’ basic human rights and not to repeat this kind of any activity in the future.”

Nepal has an appalling record of official and unofficial homophobia. A fundamentalist has recently brought proceedings in the Supreme Court of Nepal against the government calling on it to close down BDS as illegal and immoral. Observers don’t know if the arrests were inspired by that writ.

Mauro Guarinieri, Chair of the European AIDS Treatment Group, has circulated a statement to activists in several countries saying: ”Please notify Amnesty International and Human Rights Watch in your country. Please take what steps you can to put pressure on the government of Nepal to make sure these people are released safe and sound.”

comment

As we went to press we heard that the 39 members of Blue Diamond Society have now been released on bail.

Tipranavir is an investigational protease inhibitor that is now being studied in Phase-3 RESIST studies, boosted with ritonavir (500mg TPV/200mg RTV, both BID), has activity against a broad spectrum of protease resistant virus.

Previous studies showed that tipranavir remained active unless four universal protease inhibitor mutations (UPAMs, at positions 33, 82, 84 and 90) were present, usually requiring upwards of 17 individual mutations. At this meeting, a more detailed breakdown of relationship between UPAMs and virological response to tipranavir.

Doug Meyers from Boehringer Ingelheim presented an analysis of baseline resistance and associated viral response from the tipranavir Phase IIb study BI 1182.51. [1] This study was designed for patients who were too treatment experienced for the tipranavir Phase-3 studies. Patients needed to be 3-class experienced with three or more UPAMs at baseline.

After resistance screening patients were randomised to open-label tipranavir/r, amprenavir/r, saquinavir/r or lopinavir/r plus in addition to optimised background regimens for two weeks. Tipranavir/r was added to the amprenavir, saquinavir and lopinavir arms after week two.

The PK and short term virological repsonse data were reported in HTB May 2004. [2] Short-term virological response for each arm was –1.15, –0.21, –0.29 and –0.38 log10 copies/mL at two weeks for these arms respectively. After tipranavir/r was added at week two, all arms had a >1 log (median) viral load reduction. However tipranvir/r significantly reduced AUC and trough levels of the other PIs.

The percentage of responders for each boosted PI was broken down by baseline individual and combinations of UPAMs and are shown in Figure 1 and 2 below.

Figure 1: Viral load response by key mutations

Percent with >1 log reduction at week 2

Figure 2: Viral load response by key mutations

Percent with >1 log reduction at week 2

The numbers of responders in some of these groups are probably too small to comparative activity of each PI in each combination with any confidence. It would certainly be helpful to know whether tipranavir/r is more active than lopinavir/r when 82, 84 and 90 are present or with four UPAMs and less active against 33, 82 and 84, but this will require larger numbers and to control for activity of background therapy.

With small numbers the impact of other drugs used in the optimised background regimen that may have residual activity should be considered, Although these were patients who by definition have broad class resistance and therefore are unlikely to have any other active drugs, recent salvage studies have shown the importance of drug sensitivity in the background regimen. 14% of patients in the trial received T-20 and this would be expected to impact those individual responses.

However, lack of other active drugs was shown by the short-term nature of the viral load reductions that disappointingly returned towards baseline after week two, with further development of protease resistance and reduced sensitivity to tipranavir.

The study concluded:

• Patients with 3 or 4 UPAMs achieved ~ -1.2 log viral load reductions after two weeks exposure to tipranavir/r.
• Without supporting background regimens this response was short-term viral load generally began to increase again after week two.
• Different combinations of 3 UPAMs showed reduced efficacy for each of the boosted protease inhibitors studied.
• Tipranavir responses are reduced when 33, 82 and 84 are present.
• 50% of patients with 3 or 4 of these mutations had >1 log reduction in viral load.
• L90M did not affect TPV antiviral response, but is necessary to predict reduced responses to other PIs.

Although longer follow-up data and impact of individual drugs used in background regimen were not presented at the meeting it was made clear that concomitant use of T-20 had a significant impact on whether likelihood of a sustained response. Further data on these studies are expected at the ICAAC and Glasgow conferences this Autumn.

comment

The lack of information on sensitivity to drugs in optimised background regimens limits the use that can be made on this resistance data, but this early data will nevertheless be useful for clinicians who have the difficult task of selecting treatment for highly treatment-experienced patients.

People waiting to use tipranavir should strongly consider the importance of supportive active drugs if they are not to lose this option. Similarly, many people currently considering T-20, are likely to get a more durable response by also using tipranavir which is now available in the UK on an expanded access programme without CD4 entry criteria. This is in line with the current guidance for using T-20.

Although the RESIST studies allow other PIs, they do not allow therapeutic drug monitoring (TDM). This is clearly is a potential problem given the negative PK interaction data and that TDM is included in many European guidelines.

References:

1. Meyers DL, Leith J, Valdez H et al. Impact of 3 or 4 protease mutations at codons 33, 82, 84 and 90 on 2-week virologic responses to tipranavir, lopinavir, amprenavir and saquinavir, all boosted by ritonavir in Phase IIb Trial BI 1182.51. XIII Intl HIV Resistance Workshop, June 2004, Tenerife. Abstract 129. Antiviral Therapy 2004; 9:S143.
2. Large reductions in plasma PK levels of saquinavir, amprenavir and lopinavir/r levels when given with tipranavir/ritonavir. HTB May 2004.
http://www.i-base.info/pub/htb/v5/htb5-4/Large.html

The United States government has slashed its budget for sending scientists to the International AIDS Conference (IAC) in Bangkok in July, a move that will prevent the attendance of many who have had papers accepted for presentation. It is said to be a reprisal for a demonstration at the IAC two years ago against Tommy Thompson, the US Secretary for Health and Human services.

Two years ago the US department of Health spent $3.6 million sending 236 people to the IAC conference in Barcelona, but the Department of Health and Human Services (DHHS) has announced that it will spend only $500,000 to send 50 US scientists and 80 from Africa.

The DHHS prevents scientists from presenting their work if their travel is not paid for by the government so many who have had their papers accepted by the conference organisers for presentation, will not be able to do so. The department will pay for 20 scientists from the Centre for Disease Control (CDC), 20 from the National Institutes of Health and 10 from the DHHS.

According to Science, a confidential email sent in March by Jack Whitescarver, the Director of the NIH Office of AIDS Research, quoted DHHS official William Steiger as saying the decision to cut the number of government scientists “was as a result of the treatment the Secretary received in Barcelona and DHHS opinion that this meeting is of questionable scientific value”. A speech in Barcelona by Tommy Thompson was drowned out by the shouts and whistles of 40 protesters who invaded the stage.

A spokeswoman for CDC told the journal Science that the agency would select scientists according to “which [talks] are most important”. NIH refused to comment.

Meanwhile, the US government is also criticised in an article for the American Foundation for AIDS Research (AmFAR) which says the President’s Emergency Plan for AIDS Relief (PEPFAR) emphasises abstinence and fidelity, advocating condoms for only those who engage in high-risk behaviors. “PEPFAR therefore ignores the group most vulnerable to HIV today — young married women.” The full report is at the AmFAR link below.

Webcasts and other coverage of the XV International AIDS Conference will be available online at http://www.kaisernetwork.org/aids2004. Kaisernetwork.org will serve as the conference’s official webcaster.

Link:

http://www.aids2004.org/

http://www.amfar.org/cgi-bin/iowa/td/feature/record.html?record=119

Patient information is a priority for the EMEA and the Agency has continuously strengthened its interaction with patients since its creation in 1995. An EMEA/CPMP (the agency’s Committee for Proprietary Medicinal Products) working group with patients’ organisations was set up in 2003 to look at issues including further improvements in the areas of transparency and dissemination of information, product information, pharmacovigilance and interaction between the EMEA/CPMP and patients’ organisations.

The group has now made detailed recommendations and proposals for action. Some recommendations, such as the provision of patient-friendly general and product-specific information material or the re-structuring of the EMEA website to facilitate access to information for patients can be implemented within the current legal framework, while others such as public hearings during the scientific evaluation process would require amendments to legislation.

Several of these recommendations require consultation with the European Commission and Member States’ competent authorities in order to arrive at a harmonised approach at European Union level. This includes harmonisation of the information provided on the package leaflet or improvement of public access to information on adverse drug reactions. Patient information has also been put at the top of the political agenda as a result of the recent review of EU pharmaceutical legislation, the work of the G10 High Level Group on Innovation and the Provision of Medicines, and recent discussions in the Council of Health Ministers. The recommendations from the EMEA working group are the first element of the Agency’s response to the G10 recommendations and the resolution of the Council of Health Ministers of 1 and 2 December 2003.

The document ‘EMEA/CPMP Working Group with Patients Organisations – Outcome of Discussions: Recommendations and Proposals for Action’ (EMEA/CPMP/5819/04/Final) is available to download as a pdf file:

http://www.ema.europa.eu/pdfs/human/patientgroup/581904.pdf

Comments should be sent by 30 June 2004 to:

patients@emea.eu.int

Source: EMEA Press release (pdf file)

http://www.emea.eu.int/pdfs/general/direct/pr/1072004.pdf

Postexposure prophylaxis (PEP) consisting of antiretroviral medication and behavioural counselling following a potential sexual exposure to HIV does not lead to an increase in high-risk behaviour in most people, according to researchers in San Francisco.

Jeffrey N Martin and colleagues conclude that their findings of “this lack of behavioural disinhibition” coupled with prior safety and feasibility data suggest that the use of PEP should be routinely considered following high-risk sexual exposures.

The researchers conducted a non-randomised trial of 397 adults with high-risk sexual or drug-use exposure within the previous 72 hours. The intervention consisted of antiretroviral medication for four weeks and five counselling sessions. Participants were followed for 12 months to record repeat requests for PEP, modifications to high-risk behaviour and the acquisition of STDs and HIV.

The majority of participants (83%) did not request a repeat course of PEP. Seventy-three percent reported a decrease compared to baseline in the number of times they performed high-risk sexual activities, 13% reported no change and 14% reported an increase. Most, (85%) had no change in the incidence of STDs, 8.5% had a decrease and 6.8% an increase. Three gay men seroconverted for HIV, none of which was associated with the presenting exposure; this represented a rate of 1.2 per 100 person years and was similar to rates in San Francisco for all gay men.

In their discussion the authors write: “Direct proof of the efficacy of non-occupational PEP in preventing HIV transmission is still needed. Although we saw no instances of chemoprophylactic failure, we would not have necessarily expected to observe any HIV seroconversions associated with the presenting exposures even without the provision of PEP, given our sample size, the low per-exposure infectivity of HIV and the likelihood that some participants had contact with uninfected sources. Therefore, our data should not be taken as evidence for the efficacy of PEP in preventing seroconversion. Unfortunately, definitive ascertainment of the efficacy of PEP following a sexual exposure through randomised placebo-controlled trials will be difficult because of the large sample size required. Until direct evidence regarding efficacy is available, decisions must nonetheless be made on how to manage individuals with high-risk sexual exposures. Given the indirect evidence of efficacy gleaned from the occupational setting and from animal studies, coupled with our findings on feasibility and safety, we believe that PEP, comprising both antiretroviral medication and risk-reduction counselling, should be routinely considered following high-risk sexual exposures.”

Ref: Martin JN, Roland, ME, Neilands T et al. Use of postexposure prophylaxis against HIV infection following sexual exposure does not lead to increases in high-risk behavior. AIDS :Volume 18(5) 26 March 2004 pp 787-792.

http://www.aidsonline.com

An Associated Press report on this can be found at:
http://www.aegis.org/news/ap/2004/AP040323.html

The guide is at:
www.aidspan.org/guides

The number of new cases of HIV diagnosed in England and Wales rose by 20% between 2002 and 2003, triggering anxiety among public health authorities. “The year on year increase we are observing in the number of newly diagnosed HIV infections is a cause for considerable concern,” said Dr Barry Evans from the Health Protection Agency, which released the figures last week. “HIV is an infection that is here to stay.”

So far, 5,047 new HIV diagnoses have been recorded for 2003, compared with 4,204 at the same time last year. This follows the 26% increase that took place from 2001 to 2002. When all reports have been counted, the 2003 total for new diagnoses is expected to exceed 7,000 — the highest ever level — and unsafe sex was “undoubtedly the driving force,” said the agency.

“We’ve got no vaccine, we’ve got no cure, but people have got accustomed to HIV in many respects,” Dr Evans told the BMJ. “The chances of having an HIV infected partner have never been greater in the UK.” The rising trend was seen in both homosexuals and heterosexuals.

Among gay men, reports received so far show there were 1,414 new diagnoses during 2003 compared with 1,195 at this time last year for 2002, although some of this is due to more prompt reporting from some centres. When the counting is over, 2,000 new cases are expected—the highest number since testing began.

Among gay men, reports received so far show there were 1,414 new diagnoses during 2003 compared with 1,195 at this time last year for 2002, although some of this is due to more prompt reporting from some centres. When the counting is over, 2,000 new cases are expected—the highest number since testing began.

Dr Evans said the rise in other sexually transmitted infections could be behind the increase in HIV reporting. It could also be partly due to people coming forward for HIV testing who may have been infected for some time.

Nevertheless, almost a third of the estimated 49,500 people who are HIV positive in Britain are thought to be unaware of their infection. Figures like this mean that the rising trend is liable to get worse before it gets better, Dr Evans said. They also mean that more needs to be done to stem the tide, says the agency.

“In the third decade of HIV, we’re in it for the long haul,” Dr Evans said. “Somehow we’ve got to reinvigorate health promotion, and we’ve got to get people practising safe sex . . . and the scare tactics of the 1980s aren’t going to work.”

Source: BMJ 2004;328:425 (21 February)

More information can be accessed at:

http://www.hpa.org.uk

Multiple micronutrient supplementation may enhance the survival of HIV-positive individuals with CD4 <200 cells/mm3 say researchers who conducted a randomised trial that enrolled 481 HIV-positive people in Thailand.

Sukhum Jiamton and colleagues in Bangkok, London and Quebec, conducted a randomised, placebo-controlled trial to examine the impact of high dose commercially available, multiple, micronutrient supplementation on survival and disease progression. Participants received either the supplement or a placebo for a period of 48 weeks, were examined clinically at 12-week intervals and CD4 counts were conducted at 24-week intervals. A subset had their plasma viral load recorded at 48 weeks.

Seventy-nine (16%) were lost to follow up and 23 (5%) died. The death rate was lower in the micronutrients arm with the mortality hazard ratios [95% confidence interval (CI)] of 0.53 (0.22-1.25; P = 0.1) overall and 0.37 (0.13-1.06; P = 0.052) and 0.26 (0.07-0.97; P = 0.03) among those with CD4 cell counts < 200 /mm3 and < 100 /mm3 respectively. The researchers report that there was no impact on CD4 cell count or plasma viral load.

The supplement used was a mix of vitamins and minerals in amounts higher than recommended daily allowances for healthy individuals, and consisted of vitamin A, betacarotene, vitamin D3, vitamin E, vitamin K, vitamin C, vitamin B1, vitamin B2, vitamin B6, vitamin B12, folacin, pantheothenic acid, iron, magnesium, manganese, zinc, iodine, copper, selenium, chromium and cystine.

The study said that since micronutrients are inexpensive and easily tolerated, their effect on the progression of HIV is an important public health question. The researchers concluded that the findings could have important public health implications in the developing world where access to antiretrovirals remains poor.

Ref: Jiamton S, Pepin J, Suttent R et al. A randomised trial of the impact of multiple micronutrient supplementation on mortality among HIV-infected individuals living in Bangkok. AIDS. 2003 Nov 21;17(17):2461-2469.

N-9 was originally developed as a detergent, and has been used for nearly 50 years as a vaginal cream that rapidly kills sperm cells. N-9 can also act to break up or irritate the cell lining, or epithelium, of the rectum and the vagina – and can make it easier for a virus or other infective organism to invade. The danger in anal sex is especially significant because the rectum has only a single-cell wall. The vagina has a wall that is about 40 cells thick.

Source: BBC News – Tuesday, 20 January, 2004

See: UK campaign to remove Nonoxynol-9 from condoms and lubricants, HTB Vol 4 No 5.

http://i-base.info/htb/11208

The British government announced in December plans to withdraw the right of foreign visitors to the UK to receive free health care in the National Health Service – what has become known as ‘health tourism’. The ban would apply to free treatment for all non-infectious diseases including HIV. The government is also consulting on whether or not to introduce compulsory HIV tests for asylum seekers and others seeking the right to remain in the UK.

Health Secretary John Reid told the Sunday Telegraph: “If there are emergencies here, and there are bone fide tourists dropping ill on the street, of course we will do what we have to do morally and legally. But we are not mugs. There is a difference between being civilised and being taken for a ride.”

Some observers say ‘Health tourism’ costs the NHS £200 million a year, although this figure has been widely questioned, and results in other patients having to wait longer for treatment. The proposals would deny free treatment to business travellers and their dependents, failed asylum seekers, and HIV-positive people seeking long-term treatment. Emergency cases would remain exempt from charges. Reid said: “Visitors need to know they will be liable to be charged for treatment.”

In a separate move, the government is consulting on compulsory HIV and TB tests for foreigners seeking permanent residence in the UK. The influential centre-left think tank the Institute for Public Policy Research has come out against the proposal, saying that screening for TB is ineffective and compulsory tests would be counter to public health by pushing the condition underground.

The IPPR says compulsory tests would:

• Compromise Britain’s reputation for responding to HIV effectively,
• Contravene the European Convention and UN conventions,
• Lead to a false sense of security, and
• Would alienate and stigmatise HIV-positive people in a way that would increase the risk of infection spreading.

Links:

Original government proposal:
http://www.doh.gov.uk/overseasvisitors/nhschargesconsult.htm

IPPR report and summary:
http://www.ippr.org/publications/index.php?book=400

The Department of Health published a strategy for dealing with hepatitis C 18 months ago and promised an action plan by the end of 2002. Graham Foster, professor of hepatology at the Royal London Hospital, said, “There is much disappointment at the lack of an action plan. Absolutely nothing is happening.”

The Health Protection Agency announced that 5,901 cases of hepatitis C were diagnosed in 2002, up from fewer than 1,000 in 1994. Foster said over the next 10 to 15 years liver disease and cancer rates would soar if no action were taken.

New drug cocktails have increased the proportion of patients who can be cured to 60%, but since the virus is symptomless in its early stages, efforts must be made to test and identify people who are infected.

William Irving, professor of virology at Nottingham University, said, “There are a lot of people out there with hepatitis C and there is a window of opportunity to treat them now before they develop liver disease.”

The blood borne virus can be spread through sharing needles, razor blades, toothbrushes and cocaine straws; tattooing; body piercing; and sex. It is 10 times more infectious than HIV via blood-to-blood contact, but less infectious than HIV via sexual contact.

A 116 page document outlining standards for HIV services in the National Health Service was published in October by the Medical Foundation for AIDS and Sexual Health (MedFASH).

They are the first nationally agreed standards for England and have been endorsed by the Department of Health, the British HIV Association and the National Association of NHS Providers of AIDS Care, who all contributed to the funding of the recommendations. The standards have been compiled after consultations lasting two years.

The detailed standards cover HIV prevention, strategies for the early diagnosis of HIV infection, empowering people with HIV, access to specialist care and support services, local primary healthcare, integrated health and social care, comprehensive sexual health care for positive people, empowerment and support for pregnant women with HIV, adult and paediatric multidisciplinary care for children, families and their carers, in-patient care, and respite, rehabilitation and palliative care for people with HIV.

The recommended standards are aimed as guidance for service providers, commissioners and users of the NHS.

Dr Patrick French, a member of the government’s Independent Advisory Group for sexual health and HIV, and chair of the expert group which helped develop the standards, said “About a third of people living with the virus do not even know they are infected and risk severe illness if not diagnosed. They may present with symptoms in a variety of healthcare settings, such as primary care or A&E. The recommended standards should help healthcare staff in such settings to work together with HIV specialists, and to access appropriate training and support through HIV service networks.”

The full recommendations can be downloaded as a pdf file from:
http://www.medfash.org.uk

Unbelievably, the Vatican is telling people across four continents that condoms do not stop HIV because they are full of holes, according to a Panorama documentary broadcast on BBC1 TV in October. Some priests even say condoms are ‘laced’ with HIV.

Cardinal Alfonso Lopez Trujillo, president of the Vatican’s Pontifical Council for the Family, told the programme in a filmed interview: “The AIDS virus is roughly 450 times smaller than the spermatazoon. The spermatzaoon can easily pass through the ‘net’ that is formed by the condom. These margins of uncertainty … should represent an obligation on the part of the health ministries and all these campaigns to act in the same way as they do with regard to cigarettes, which they state to be a danger.”

The World Health Organisation has countered the Vatican’s claims, calling them “incorrect” and “dangerous”. The WHO says condoms can break or slip off but there are not holes through which the virus can pass. It says “consistent and correct” use of condoms cuts the risk of infection by 90%.

A scientific research group that included the WHO and the US National Institutes of Health, carried out research that found that “intact condoms are essentially impermeable to particles the size of STD pathogens including the smallest sexually transmitted virus”.

Cardinal Trujillo dismissed the evidence, saying: “They are wrong about that … this is an easily recognisable fact.”

Panorama found the Vatican’s advice repeated by Raphael Ndingi Nzeki, the archbishop of Nairobi, Catholic nuns and church leaders around the world. Gordon Wambi, the director of an HIV clinic in Lwak, near Lake Victoria, told the programme that the church had prevented him distributing condoms. “Some priests have even been saying that condoms are laced with HIV/AIDS,” he said.

The Catholic Church has consistently condemned the use of condoms whether for use as contraceptives or for health protection.

More than 40 million people have HIV, most with no access to treatment.

Links:

Transcript and online (RealAudio) access to Panorama
http://news.bbc.co.uk/1/hi/programmes/panorama/3147672.stm

UN Statement:
http://www.un.org/apps/news/story.asp?NewsID=8534&Cr=&Cr1=

A report published in July AIDS describes the epidemiology of HIV infection acquired in Africa and among African communities in the UK using national HIV and AIDS surveillance data to the end of December 2001.

The investigators report 9,993/48,226 (21%) of all reported HIV infections diagnosed during the study period were probably acquired in Africa and that of these 90% of these infections were acquired heterosexually.

Numbers of diagnoses of HIV infection acquired in Africa have increased rapidly, with rises in infections from southeastern and southern Africa predominating recently. Among those living with diagnosed HIV infection in 2000, 4,883/21,291 (23%) were described as black African, 81% of whom lived in London. The proportion living in London has declined over successive prevalence surveys.

The authors conclude: “The future of HIV infection among Africans living in the United Kingdom is unpredictable, and continued surveillance of the situation is essential.”

Ref: Sinka, K; Mortimer J; Evans, B et al. Impact of the HIV epidemic in sub-Saharan Africa on the pattern of HIV in the UK AIDS 2003, 17: 1683 -1690

Pharmacies in the Netherlands started selling medical marijuana in September – to people with a doctor’s prescription. More than 2,000 pharmacies are legally obliged to stock the drug and to provide advice on how to use it. They encourage people to make cannabis tea rather than smoke it. The drug is sold in 5g bags and in two strengths and costs 40 euros for the milder version and 50 euros for the stronger version – which is about twice the price charged in Dutch coffee shops.

About 7,000 to 10,000 patients with a variety of conditions including, AIDS, cancer, multiple sclerosis, Tourette’s syndrome and rheumatoid arthritis will be entitled to prescriptions, and for the first time the drug will be covered by health insurance.

Marijuana remains officially prohibited under Dutch law, although the authorities tolerate the sale of small quantities. The Dutch parliament approved the change of policy on medical use by a large majority in 2001. Medical marijuana has been legal in Holland since March this year but pharmacies were given an extra seven months to stock their shelves and educate staff. Medical marijuana growers and pharmacies need licences exempting them from prosecution.

Canada, Germany, Australia and 14 states of the United States allow restricted use of medicinal marijuana and they, as well as Britain where the government is considering a similar move, will be carefully watching the Dutch experience.

The former Medicines Control Agency has received a damning blow from the House of Commons Committee of Public Accounts.

The committee’s report, Safety, Quality, Efficacy: Regulating Medicines in the UK, criticises the agency for its “lack of dynamism” in improving public health and for its “non-existent” public profile, which made it difficult for it to function as a provider of safety information.

The agency was, until earlier this year, responsible for protecting public health by ensuring the safety, quality, and efficacy of the one billion medicines that are prescribed and sold over the counter in the United Kingdom each year. It inspects manufacturing and supply facilities and monitors the risks and benefits of existing medicines.

The agency was set up in 1989. In April 2003, it merged with the Medical Devices Agency to form the Medicines and Healthcare Products Regulatory Agency, which now inherits the responsibilities of the Medicines Control Agency.

The committee looked at the Medicines Control Agency’s performance against its key objectives of promoting and safeguarding public health through the regulation and provision of information on medicines, and its service to stakeholders.

The report was critical of the poor quality of information leaflets and labels, designed to alert patients and doctors to potential risks of medication, and the low level of reporting of adverse reactions to medicines by doctors. These were cited as evidence of the lack of dynamism to drive further improvements in the protection of public health.

The report added that the widespread but unmonitored practice of prescribing drugs to children that, although licensed, were not specifically approved for paediatric use was also cause for concern.

The committee also highlighted the irony that an agency whose mission was to put across safety messages to the public had a non-existent public profile. Even doctors had little awareness of its role. Unlike the US Food and Drug Administration, the agency failed to embrace advertising and awareness campaigns necessary for developing a relationship with the public, says the report.

The committee hopes that the creation of the Medicines and Healthcare Products Regulatory Agency will be a good opportunity to rectify some of the failings of its predecessor. It wants to see the new body develop training for doctors on monitoring the safety of medicines, as well as establishing an effective communications and awareness strategy for conveying safety messages both to the public and to health practitioners.

Edward Leigh MP, chairman of the Committee of Public Accounts, said: “It is simply unacceptable that the agency’s efforts to drive improvements in the protection of public health have been so lacklustre.”

Safety, Quality, Efficacy: Regulating Medicines in the UK (26th report of session 2002-3) is available at:
http://www.parliament.uk

Source: BMJ 2003; 327:10 (5 July)

http://bmj.com/cgi/content/full/327/7405/10

The 5 June edition of the New England Journal of Medicine includes a two-year follow-up report from the first successful heart transplant, in January 2001, in an HIV-positive individual.

The recipient was a 39-year-old research scientist who had been diagnosed HIV-positive in 1992 and his history of opportunistic infections including KS, gastrointestinal CMV, disseminated MAI and PCP. Nadir CD4 count was 0 cells/mm3 in April 1994.

Antiretroviral therapy included nucleosides only until 1995 and when the first protease inhibitors became available and CD4 count increased to 400 by 2000 with no additional OI complications.

Echocardiography in 1995 revealed an ejection fraction of less than 25%, which progressively fell to 10% by October 1999. Assessment included attributing dilated cardiomyopathy to previous use of daunorubicin treatment.

Viral load has been maintained <50 copies/ml since 1998 including throughout the transplantation and post transplant follow-up. CD4 count dropped to <50 cells/mm3 during the period immediately surrounding the operation, but did not result in recurrence of previous AIDS-related infections. Sensitive serial monitoring included PCR for HHV-8 (associated with KS).

The report notes that “the clinical course has been marked by frequent episodes of rejection (grade 0 to 3A), revealed by serial endomyocardial biopsies; these episodes have not been associated with haemodynamic changes and have been treated with intermittent glucocorticoids (the data are summarised in Table 1). Other complications after transplantation have included an exacerbation of gouty arthritis, recurrent anal condyloma, and the development in March 2002 of anaemia (hematocrit, 25%) that was initially attributed to distal esophagitis–gastritis on endoscopic examination in April 2002. The patient recently became transfusion-dependent, despite the resumption of erythropoietin therapy (Table 2), and currently requires transfusions of packed red cells every two to three weeks. However, he continues to work full-time and exercises regularly.

Notably, the HAART in this case is a full-dose ritonavir-based regimen, and even more surprisingly this continues today. The significant interactions with ritonavir and calcineurin antagonists used after transplantation required particularly careful adjustment.

Ref: Calabrese L, Albrecht M, Zackin R et al. Successful cardiac transplantation in HIV-1-infected patient with advanced disease, NEJM 2003;348:2323-2328

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Access to, and more importantly successful results from, solid organ transplants have increased in the last five years, largely as a result of HAART therapy. HIV-positive people are no longer automatically excluded from life extending surgery because their lives are assumed to be too short to justify the costs involved.

Highest success rates have been reported with kidney transplants, and the growing success with liver transplants for people with ESLD caused by hepatitis C is still complicated largely by reinfection. Use of immune-suppressing drugs essential in all transplants do not appear to present increased risks for HIV-positive patients compared to people who are HIV-negative so long as they have a minimal baseline CD4 count (currently >200 cells/mm3 for kidney and >100 cells/mm3 for liver transplants).

They identified 42 studies submitted to the Swedish drug regulatory authority to secure marketing approval for five antidepressant drugs. These studies were then compared with studies actually published between 1983 and 1999.

They found evidence of three sources of bias: duplicate publication, selective publication, and selective reporting. For instance, 21 studies contributed to at least two publications each, and three studies contributed to five publications. Studies showing significant effects of a drug were published as stand alone publications more often than studies with non-significant results. The tendency to report the more favourable results only, in studies actually published, was a major cause for bias.

These results should not be used to dispute the value of analysing the medical literature, say the authors.

However, they are likely to be valid for other classes of drugs, so for anyone who relies on published studies alone to choose a specific drug, they should be a cause for concern.

Without access to all studies (positive as well as negative, published as well as unpublished) any attempt to recommend a specific drug is likely to be based on biased evidence, they conclude.

Source: BMJ press release

http://bmj.com/cgi/content/full/326/7400/1171

The European Medicines Evaluation Agency (EMEA) has rejected Serono’s application to license its formulation of recombinant Human Growth Hormone, a compound with anabolic effects, (rHGH, non-proprietary name: Somatropin; tradename: Serostim) for AIDS-related wasting syndrome.

Serostim was designated as an orphan drug in August 2000, which allows for additional support from the European agency and reduced costs, for compounds to treat very low incidence diseases.

The reasons given for rejection by the Committee for Proprietary Medicinal Products (CPMP, the agencies scientific committee) included:

• Difficulty to identify a target population due to the heterogeneity in terms of body composition and antiretroviral (ARV) options included in Study GF 9037
• Doubts about the clinical relevance of the primary endpoints studied of improved work output and lean body mass (LBM). Although the questionnaire on the Quality of Life (QoL) showed improvements across all the domains it is still unclear what kind of a benefit might be expected from treatment with Serostim in a clinical setting.
• Long-term efficacy data under controlled conditions are lacking. These are considered necessary to determine the maintenance of the effect of Serostim or the rebound phenomenon, whether the therapy should be intermittent or systematic and whether there would be a need for dose adjustment.
• There is concern about the long-term safety profile of Serostim in the context of repeated courses of treatment in AIDS patients.

The drug received accelerated approval from the FDA for AIDS-wasting in the United States in July 1996.

Serono disagree with the EMEA interpretation of the trial results (which were presented at the IAS World AIDS Conference in Barcelona last year, Abstract ThPeB7352, and others).

Source: EMEA Press Release and Summary of Opinion

Links:

Serono Press Release
http://www.serono.com/media/stories2003/20030430_en.jsp?major=4&minor=1

Useful article on Human Growth Hormone
http://www.thebody.com/sfaf/winter03/hgh.html

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The main problem with this study was the diverse patient population, with a minority of patients fullfilling the definition of true wasting. r-HGH has a clear anabolic effect in most study participants and this can reverse or stop the loss of lean body mass in HIV-positive patients who have experienced weight loss.

Side effects include induction of diabetes mellitus in patients with abnormal glucose tolerance and arthralgia, especially at the 6mg/day dose. Lipoatrophy may worsen due to subcutaneous fat loss.

Serono is also trying to get rHGH approved for lipodystrophy – reversal of buffalo hump and abdominal visceral fat have been reported during treatment, but symptoms generally return within a few months of discontinuing treatments.

The government has failed to meet almost all the targets set in “The Health of the Nation” in 1992, Adler wrote in the 1 April issue of Sexually Transmitted Infections. Chlamydia cases have risen 73 percent in the past five years, while cases of genital herpes rose 13 percent in the same period. The number of new HIV cases has increased dramatically and is expected to reach 33,930 by 2005. Infectious syphilis cases, which were rare in England, increased 374 percent since 1997, with 697 cases diagnosed in 2001. In the past 12 months alone, syphilis cases increased 116 percent.

Additionally, the rate of teenage conceptions among those under age 16 remained unchanged since 1992 – 8.3 conceptions per 1,000. That is well above the target of 4.8 conceptions per 1,000.

Adler said the ú47.5 million (US$74.6 million) the government allocated for its sexual health strategy would not even cover one aspect of the strategy: a Chlamydia screening program. Sexual health clinics are struggling to cope with demand, with some people in large urban centers forced to wait a month for an appointment. The number of consultants in genito- urinary medicine is 90 percent below target.

“We share Professor Adler’s concerns about worsening sexual health and recognize that there are important public health issues to be addressed,” said a Department of Health spokesperson. “This is why we have developed the first-ever national sexual health and HIV strategy.” The £47.5 million announced with the strategy has been committed to support initiatives and help improve key services, he said.