Science & Medicine
Early Initiation of Antiretroviral Therapy Improves HIV Survival Rates, Study Says
[Apr 30, 2009]
The New York Times on Thursday examined a study that found asymptomatic HIV-positive people who delayed antiretroviral treatment until their disease reached an advanced stage faced higher mortality rates than those who initiated treatment earlier. According to the Times, current national guidelines recommend starting HIV-positive people on antiretroviral treatment when CD4+ T cell counts fall below 350; however, the recent study suggests that initiating treatment earlier could reduce the risk of death. The study, as well as a related editorial, appeared online in the New England Journal of Medicine earlier this month and both will appear in the April 30 edition of the journal. In addition, a separate study published online earlier this month in the journal Lancet developed similar conclusions about the benefits of earlier antiretroviral therapy initiation, the Times reports.
For the NEJM study, researchers led by Mari Kitahata, director of clinical epidemiology at the Center for AIDS and Sexually Transmitted Infections at the University of Washington, tracked survival rates for 17,517 asymptomatic HIV-positive people in the U.S. and Canada who received care from 1996 to 2005 and who had never previously taken antiretroviral therapy. For their first analysis, the researchers examined a group of 8,362 patients, 2,084 of whom started therapy when CD4+ counts were between 351 and 500. They also examined 6,278 participants with similar CD4+ counts who delayed therapy until their counts declined below 350. According to the study, the patients who delayed treatment had a 69% higher risk of death compared with those who initiated treatment earlier. For the researchers' second analysis, they examined 9,155 HIV-positive people with CD4+ counts of more than 500. Of those, 2,220 started therapy within six months, while 6,935 delayed therapy. Among those who postponed treatment, 3,881 experienced a decline in CD4+ levels and 539 started antiretroviral treatment within six months of having a CD4+ count of 500 or less. In addition, the researchers found that those who deferred therapy had a 94% greater mortality risk than those who initiated treatment earlier.
According to Kitahata, the study examined "one of the most important questions in the last decade: what the optimal timing is for starting therapy." She added that the recent research "provides evidence that patients would live longer if antiretroviral treatment was begun when their CD4+ count was above 500." According to the Times, the study is "not the final word on the matter" (Rabin, New York Times, 4/30).
The study is available online.
Two related editorials also appeared in the April 30 edition of NEJM. Summaries appear below.
"When To Start Antiretroviral Therapy: Ready When You Are?:" Although the results of Kitahata's study are "striking," they "cannot be considered definitive evidence that everyone with HIV should start receiving antiretroviral therapy," Paul Sax and Lindsey Baden of the Division of Infectious Diseases at Brigham and Women's Hospital write. They continue that despite the researchers' "relatively large" sample size and use of "advanced statistical methods," their study was not a "randomized trial, and the patients who chose to begin therapy early might have differed in other important ways from those who chose to defer therapy -- ways that improved survival but were not measured." Sax and Baden add that "a conclusion would require data from a randomized, prospective clinical trial, and at least three such studies are either ongoing or planned." They conclude that despite the study's "limitations," evidence supporting the benefits of earlier antiretroviral therapy "continues to increase, making strategies to identify patients with HIV infection before the onset of substantial immunodeficiency all the more compelling" (Sax/Baden, New England Journal of Medicine, 4/30).
"Rationing Antiretroviral Therapy in Africa: Treating Too Few, Too Late:" Although the international health community has achieved "striking advances" in increasing access to antiretroviral treatment in Africa, "too few people are receiving treatment" and health workers "are waiting until people are symptomatic" before administering antiretroviral therapy, Nathan Ford -- head of the medical unit of Medicines Sans Frontieres in Cape Town, South Africa, and research associate at the School of Public Health and Family Medicine at the University of Cape Town -- and colleagues write. They continue that although "delaying therapy may mean saving money on drugs," the "long-term cost of such delays is increased substantially by the need for more intensive clinical care, decreased income and likely regimen switches." In addition, later antiretroviral initiation "encourages the spread of tuberculosis" and could increase the risk of HIV transmission "by allowing patients to remain viremic longer," the authors write. They conclude, "The battle to start providing antiretroviral therapy in the developing world has been won. The battle to provide the best care we can is just beginning" (Ford et al., New England Journal of Medicine, 4/30).
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Public Health & Education
Using Social Networks Effective Strategy To Reach Populations at Risk of HIV/AIDS, Study Finds
[Apr 30, 2009]
Using HIV-positive people's social network is "an efficient, high-yield" method of contacting their partners who are at high-risk for the virus and providing them with testing and other HIV-related services, CDC researchers said in a recently published study, Reuters Health reports.
For the study, which appears online in the American Journal of Public Health, researchers led by Lisa Kimbrough documented the results of a social networks project that took place between October 2003 and December 2005. For the project, nine community-based organizations in seven cities signed up 422 recruiters. The initial recruiters were HIV-positive, and later recruiters could be HIV-negative but at a high-risk for HIV. The most commonly self-reported behavioral risk factor was having had high-risk heterosexual sex at 46%. The average age of the recruiters was 41.7, and 60% were HIV-positive. Sixty-three percent were men, and 61% were black.
Recruiters referred peers, known as network associates, into the study. On average, the number of network associates referred and tested per recruiter was 7.4. The report found that of the 3,172 network associates referred, 177, or 5.6%, tested HIV-positive and two-thirds were connected to HIV care and services. According to the study, the HIV prevalence among those tested as a result of the project was about five times greater than the prevalence found in other CDC-funded counseling, testing and referral projects.
The researchers said that this was a "significant public health achievement, because persons who learn that they are HIV-positive tend to reduce their high-risk behaviors to avoid infecting others and have the opportunity to access medical care and other services to improve their personal health." They added that the social networking strategy was more effective and a better use of staff time at contacting undiagnosed HIV-positive people, compared with the common approach of partner counseling and referral services (Reuters Health, 4/29).
An abstract of the study is available online.
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Burundian HIV/AIDS Advocates Express Concern Over New Law Outlawing Homosexuality
[Apr 30, 2009]
Some HIV/AIDS advocates in Burundi and international human rights groups have expressed concern about a new law that criminalizes homosexuality in the country, IRIN/PlusNews reports. Although Burundi's Senate voted against the draft bill in February, the lower parliament house reversed the decision last month, and President Pierre Nkurunziza signed the bill into law on April 22. According to the new statute, people found guilty of engaging in consensual same-sex relations could face two to three years in prison and a fine of about $84.
Several advocacy and international rights organizations -- including Human Rights Watch, Burundi's National Association To Support HIV-Positive People, or ANSS, and the local rights group Ligue Iteka -- in response to the law issued a statement describing the potential consequences of the statute. "We regret that the law will hamper Burundi's attempts to fight AIDS by further marginalizing an at-risk population," they wrote, adding, "We urge the government to act promptly to decriminalize homosexuality." Georges Kanuma, chair of the Association for the Respect and the Rights of Homosexuals, or ARDHO, said his organization's activities "will be hampered by this law." ARDHO -- which has operated since 2003 despite never gaining official recognition as a nongovernmental organization -- distributes condoms and lubricants and also raises awareness of HIV among men who have sex with men. Kanuma said the group is closing its offices in Burundi's capital of Bujumbura "because we are afraid that with the new law we may be arrested."
According to Kanuma, most Burundians are not aware of the existence of MSM in their communities. Kanuma said ARDHO hopes to meet with Burundi's National AIDS Control Council, or CNLS, to see if the council also intends to halt activities targeting MSM. According to IRIN/PlusNews, CNLS in its most recent national strategic plan identifies MSM as vulnerable to HIV and acknowledges the need for prevention activities targeting this community (IRIN/PlusNews, 4/28).
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Solomon Islands' Media Should Increase HIV/AIDS Awareness, Combat Stigma, Official Says
[Apr 30, 2009]
Media outlets in the Solomon Islands should undertake efforts to increase awareness about HIV/AIDS and counteract the stigma associated with the disease, Joe Weber, Oxfam International representative for the country, said recently at the close of a week-long media training on HIV/AIDS and sexually transmitted infections, PINS/Solomon Star News reports. The meeting -- funded by Oxfam and organized by the Solomon Islands Planned Parenthood Association -- included 20 media personnel from various organizations in the country's capital of Honiara.
According to Weber, many people in the Solomon Islands have limited knowledge about HIV/AIDS and are unaware of strategies to protect themselves and their communities against the disease. He said the media can play a role in reversing this trend by providing basic information about HIV/AIDS, its impact on society and how it can hamper development goals. Weber suggested that media outlets could run stories about people living with HIV in order to shed light on the disease and reduce fear associated with the virus. He continued that these stories could describe how people live with HIV, as well as how families and communities deal with its effects. In addition, Weber said the media could explore how gender inequality and gender-based violence increase vulnerability to HIV among women. Weber also encouraged participants to report on nongovernmental organizations and faith-based groups that undertake efforts to prevent HIV/AIDS. According to Weber, media outlets can help foster a supportive environment that could help curb the spread of HIV in local communities (Kivo, PINS/Solomon Star News, 4/28).
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In The Courts
Canadian Court To Determine Constitutionality of Law Preventing Supervised Drug-Injection Sites
[Apr 30, 2009]
The British Columbia Court of Appeals this week is hearing a case to decide whether certain sections of Canada's Controlled Drugs and Substances Act that prevent injection drug users from accessing services at the supervised drug-injection facility Insite in Vancouver, British Columbia, are constitutional, Toronto's Globe and Mail reports (Stueck, Globe and Mail, 4/28).
Insite, which is funded by the British Columbia provincial government and has received research funding from the Canadian government, includes booths for IDUs to inject drugs as well as room in which users can be monitored for overdoses. Vancouver has one of the highest illegal drug use rates in North America, with as many as 12,000 IDUs in the Vancouver metropolitan area, 30% of whom are HIV-positive and 90% of whom have hepatitis C. When the facility opened in September 2003, it received a three-year exemption from CDSA, which bans heroin use, to conduct a pilot study on the site's role in reducing drug use and crime in Vancouver's Downtown Eastside (Kaiser Daily HIV/AIDS Report, 8/8/08). The exemption was extended to the end of 2007 and later to June 30, 2008.
Two individuals last year initiated court proceedings to allow Insite to continue operation after June 30, 2008. B.C. Supreme Court Justice Ian Pitfield in May 2008 issued a ruling in the case, saying that certain sections of the CDSA relating to drug possession and trafficking are inconsistent with the Canadian Charter of Rights and Freedoms. "The blanket prohibition contributes to the very harm it seeks to prevent," Pitfield wrote in his ruling, adding, "It is inconsistent with the state's interest in fostering individual and community health and preventing death and disease."
In his ruling, Pitfield gave the Canadian government until June 30, 2009, to rewrite the CDSA possession and trafficking provisions, which would enable Insite to continue operation. Insite received a constitutional exemption in the interim allowing the facility to continue to operate until the CDSA sections were rewritten. The federal government appealed Pitfield's ruling on June 3, 2008.
Robert Frater, an attorney for the Canadian government, on Monday argued that the federal government is not required to provide a supervised drug-injection facility, such as Insite, for IDUs. "It should be stressful to break the law," Frater said, adding, "The government is under no obligation to provide (its citizens) with a safer way of breaking the law." Insite attorney Joseph Arvay said the CDSA "stands between ill people and the health care they need" and "deprives [IDUs] of their rights to life and security of person" (Globe and Mail, 4/28).
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