Kaisernetwork.org (Washington, DC)
7 November 2008
Global Challenges
Zimbabwe Returns $7.3M in Misused Grant Money to Global Fund
[Nov 07, 2008]
The Reserve Bank of Zimbabwe has returned $7.3 million in misused grant money to the Global Fund To Fight AIDS, Tuberculosis and Malaria, Global Fund Executive Director Michel Kazatchkine said Friday, Reuters reports (Williams, Reuters [1], 11/7).
The money, which was part of last year's $12.3 million grant, was not returned sooner, because officials in Zimbabwe said they lacked foreign currency. Although John Parsons, the Global Fund inspector general, did not speculate on how the $7.3 million of the grant was spent, he said it had not been used for its intended purpose (Kaiser Daily HIV/AIDS Report, 11/3). Local media in Zimbabwe reported that the Reserve Bank dispersed the Global Fund money to purchase tractors and televisions. However, the bank denied the allegation, and Kazatchkine said Global Fund officials have "no evidence of fraud" (Reuters [1], 11/7).
The Global Fund on Thursday had said it would not grant new funding to Zimbabwe until the misused funds were returned, the AP/Boston Globe reports. The Global Fund's board on Friday was expected to consider Zimbabwe's request for $400 million in Round 8 funding (Sharma, AP/Boston Globe, 11/7). The Global Fund's Technical Review Panel recently had recommended the funding be approved (Kaiser Daily HIV/AIDS Report, 11/3). Kazatchkine on Friday said the Global Fund "greatly appreciates" the return of the funds, adding that it will "accelerate the life-saving activities of the malaria, TB and HIV programs in Zimbabwe" (AP/Boston Globe, 11/7). According to Reuters, Zimbabwe has one of the highest HIV prevalence rates worldwide and has received $88 million in Global Fund grants since 2002 (Reuters [1], 11/7).
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Botswana To Begin HIV Prevention Campaign That Focuses on Male Circumcision
[Nov 07, 2008]
Male circumcision will be a primary focus of Botswana's HIV/AIDS prevention efforts, the Sunday Standard reports. The decision to focus on male circumcision as part of a boost in prevention efforts was announced at the annual planning conference of the African Comprehensive HIV/AIDS Partnerships, which was held recently in Francistown. Presenters at the conference -- themed "Refocusing HIV Prevention: Using Evidence to Inform Future Programming" -- agreed that Botswana must focus on prevention, as well as treatment, care, behavior change and HIV testing. The conference marked the close of Botswana's national strategic HIV/AIDS framework for 2003 to 2009 and brought the country into a new national strategic framework through 2016, the Standard reports.
Mabel Kejelepula, a representative of the HIV/AIDS prevention and care department at the Ministry of Health, said that the department already has begun developing strategies to increase male circumcision and made negotiations with medical providers and physicians. The health ministry also is aiming to find partners to share the costs of a circumcision program, the Standard reports. An unnamed private physician in Francistown said, "In the face of conclusive evidence that uncircumcised men are at a much greater risk of becoming infected with HIV, it should be conclusive that male circumcision should be seriously considered as an additional means of preventing HIV."
Although research shows few men have been circumcised in Botswana, it is an accepted practice throughout the country (Ganetsang, Sunday Standard, 11/5).
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Health Officials in Scotland Uphold Ban on Blood Donations From MSM
[Nov 07, 2008]
Scottish health officials Tuesday rejected calls to allow men who have sex with men to donate blood, citing concerns about the number of HIV cases in the population, The Scotsman reports. National Director of the Scottish National Blood Transfusion Service Keith Thompson said the lifetime ban against MSM is in place to ensure the safety of blood donations, but advocates have said that the restrictions are discriminatory and that the ban hinders efforts to alleviate blood shortages in the country. The Scotsman reports that 86% of new HIV cases in Scotland are recorded among MSM.
Thompson said that approximately one-third of blood donations that were found to contain HIV were traced to MSM and that it is not possible at this time for blood service staff to safely differentiate between MSM whose behavior would put them at high risk for HIV and those whose behavior would not. Careful donor selection is the only defense against this and any issues surrounding the screening of blood donations, SNBTS officials said, adding that other groups that are prevented from donating blood include people who have had sex with a commercial sex worker, injection drug user or in a country with a high HIV burden in the past year.
The announcement was in response to a petition submitted to the Scottish Parliament calling for a review on donation rules to allow certain MSM to give blood. The petition was supported by groups such as Stonewall Scotland, the National Union of Students and Bloodban, which called the restrictions "outdated, stereotypical and discriminatory towards healthy" MSM. Calum Irving, director of Stonewall Scotland, said the group believes the "blood ban is discriminatory and should be lifted," adding that SNBTS is "applying one rule for gay people and another for straight people." A Scottish government spokesperson said that officials "recognize that many [MSM] sincerely wish to help patients by giving blood and may be frustrated as a result of this rule. Advances in blood transfusion safety procedures may allow gay and bisexual men to donate in the future, but, until then, priority has to be given to securing the safety of the blood supply" (Moss, The Scotsman, 11/5).
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Science & Medicine
Effectiveness of Bone Marrow Transplant in Suppressing HIV Creates Hope for Gene-Therapy Strategies in Treating Virus, Wall Street Journal Reports
[Nov 07, 2008]
The Wall Street Journal on Friday examined the case of an HIV-positive person who underwent a bone marrow transplant to treat leukemia and who has had undetectable HIV viral loads for almost two years. The procedure -- performed by German hematologist Gero Hutter of Berlin's Charite Medical University on a 42-year-old American living in the city -- "is stirring new hope that gene-therapy strategies on the far edges of AIDS research might someday cure the disease," the Journal reports.
For the procedure, Hutter, who is not an HIV/AIDS specialist, replaced the patient's bone marrow cells with those from a donor with a naturally occurring gene mutation that provides immunity to almost all strains of HIV by preventing the CCR5 molecule from appearing on the surface of cells. According to the Journal, about 1% of Europeans, and even more in northern Europe, inherit the CCR5 mutation from both parents, and people of African, Asian and South American descent almost never carry it. Of 80 compatible blood donors living in Germany, Hutter's colleague Daniel Nowak found one who had inherited the mutation from both parents on the 61st sample he tested. According to the Journal, because immune-system cells are created in bone marrow, "transplanting mutant bone-marrow cells would render the patient immune to HIV into perpetuity, at least in theory."
The Journal reports that prior to the transplant, Hutter administered a standard regimen of powerful drugs and radiation to kill the patient's bone marrow cells and many immune-system cells, which may have helped the treatment succeed because the procedure killed many cells that harbor HIV. Transplant specialists then ordered the patient to stop taking his antiretroviral drugs when they transfused the donor cells because they were concerned that the drugs might undermine the cells' ability to survive in their new host. Although the plan was to resume the antiretroviral regimen once HIV re-emerged in the patient's blood, more than 600 days later, standard tests have not detected HIV in his blood, or in brain and rectal tissues where the virus often hides.
David Baltimore, who won a Nobel prize for his research on tumor viruses, said the case is "a very good sign" and a virtual "proof of principle" for gene-therapy approaches, but he cautioned that it could be a fluke. However, researchers who recently have reviewed the case believe that although it is likely that some HIV remains in the patient, it cannot "ignite a raging infection, most likely because its target cells are invulnerable mutants." According to the Journal, the researchers agreed that the patient is "functionally cured." Nevertheless, research has shown that blocking CCR5 can have fatal consequences, and bone-marrow transplants, which are given only to later-stage cancer patients, can result in death among 30% of patients. The Journal reports that although "scientists are drawing up research protocols to try this approach on other leukemia and lymphoma patients, they know it will never be widely used to treat AIDS because of the mortality risk."
Although re-engineering a patient's own cells through gene therapy could be a safer alternative, such strategies face "daunting technical challenges," the Journal reports. However, several research groups are testing different approach to treating HIV/AIDS, "[e]xpecting that gene therapy will eventually play a major role in medicine" (Schoofs, Wall Street Journal, 11/7).
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Study Compares Antiretroviral Treatments Among HIV-Positive Mothers Who Received Nevirapine During Labor
[Nov 07, 2008]
A recent review of a clinical study funded by NIH comparing antiretroviral treatment regimens that contained either nevirapine or ritonavir-boosted lopinavir found that ritonavir/ lopinavir is more effective than nevirpaine among HIV-positive women who previously took a single-dose of nevirapine to prevent mother-to-child HIV transmission, South Africa's Business Day reports (Kahn, Business Day, 11/6). The study, called Optimal Combination Therapy after Nevirapine Exposure, has two purposes: to determine which of the two antiretroviral regimens is more effective for women who previously took single-dose nevirapine to prevent MTCT; and to examine whether taking single-dose nevirapine to prevent MTCT during labor subsequently compromises the effectiveness of nevirapine as a component of therapy for HIV-positive mothers (NIAID bulletin, 1028).
The study included 745 women in seven African countries and compared two antiretroviral regimens -- nevirapine, emtricitabine and tenofovir, or lopinavir-boosted ritonavir, emtricitabine and tenofovir -- in women who received nevirapine during labor and those who did not. According to Business Day, a routine interim review of the trial by an independent data safety monitoring board on Oct. 6 found that women who had nevirapine-resistant strains of HIV fared better if they were put on a regimen that did not contain the drug. Thirty-eight percent of the women who had developed resistance and were treated with a nevirapine-based regimen either died or failed to suppress the virus, while all of the women who had nevirapine-resistant strains of HIV but received a regimen containing lopinavir-boosted ritonavir were alive and suppressing the virus.
Francesca Conradie, a researcher from the University of the Wiwatersrand Clinical HIV Research Unit, said, "I'm not saying nevirapine should not have been given to these women -- it was the best we had at the time. What we can do now is protect nevirapine (to ensure it can be safely used in their subsequent treatment)," she said. According to Conradie, women who received nevirapine during childbirth and are now being treated with nevirapine-based regimen should be closely monitored to make sure the drugs are effectively suppressing HIV. They also should be switched to Kaletra -- known generically as lopinavir/ritonavir -- if they show signs of resistance, she said. "The longer you leave them on a failing regimen, the greater the risk that they will become resistant to all the drugs they are taking," Conradie added.
Business Day reports research is continuing into the efficacy of nevirapine and lopinavir-boosted ritonavir in women with no prior exposure to nevirapine (Business Day, 11/6).
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Drug Access
HIV-Positive People in Cameroon Face Resistance to Second-Line Antiretrovirals
[Nov 07, 2008]
While countries worldwide are scaling up their antiretroviral treatment programs, more people living with HIV/AIDS are expected to develop resistance to their drug regimens and lack access to more expensive alternative therapies, IRIN/PlusNews reports. According to IRIN/PlusNews, although the number of people who have developed resistance to second-line antiretrovirals remains small, "the challenge is trying to keep these numbers down." Many HIV/AIDS experts say that the main cause of drug resistance is poor adherence to treatment regimens.
In Cameroon, IRIN/PlusNews reports that the case of Marie Gisele Tientcheu, an HIV-positive advocate who developed resistance to second-line antiretrovirals and could not access treatment in the country, "has thrown the spotlight" on the problem. Although there are no official statistics on resistance rates in Cameroon, a 2007 study on patients receiving care at a hospital in the capital of Yaounde found that 4.4% of patients were developing resistance after one year of treatment. However, Charles Kouafang, head of the hospital's AIDS unit, said the rate of resistance had fallen from 2002, when a similar study showed that 16.2% of patients developed resistance after only eight months of treatment. Kouafang said that the 2002 data reflected the high cost of antiretrovirals and that the situation improved after the government introduced no-cost treatment in 2007. However, he said "the fact that cases of resistance still occur is a public health concern." According to IRIN/PlusNews, approximately 55,000 HIV-positive Cameroonians receive antiretroviral treatment, and GTZ -- with participation from Cameroon's Ministry of Health and National AIDS Commission -- in August established an awareness campaign encouraging patients to adhere to their drug regimens.
Caroline Kenkem, deputy executive secretary of the Cameroon Network of People Living With HIV, said that given the issue of drug resistance among HIV-positive people living in the country, it is "imperative" that third-line antiretrovirals be distributed. However, Alain Fogue, president of the Cameroon Movement for Advocacy and Access to Treatment, said that it is unlikely to happen. Fogue said, "I don't think the authorities are planning to provide third-line" antiretroviral in Cameroon, adding, "I don't even know if they are aware of this situation, because managing the second-line protocol is hard enough." According to IRIN/PlusNews, organizations of HIV-positive people in Cameroon have launched an appeal to the government to address the issue. Fogue said, "We feel there is no real policy on medication or on providing care and support for patients. It feels like we're trying to get our voices heard, despite many years of fighting and demonstrations for political action" (IRIN/PlusNews, 11/5).
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