More news on HIV and children

The AIDS 2012 conference also featured new research on several other areas of importance for children and adolescents:

• Early HIV diagnosis and treatment that preserves the health of adults is likely to keep children in school for longer, a Ugandan study shows, and results in less household poverty.
• More evidence came from Malawi to show that HIV testing at immunisation clinics is a good way to increase rates of HIV diagnosis in both infants and their mothers, at an early point during the breastfeeding period.
• Male partner involvement can increase the chances that mothers will test for HIV during pregnancy.

For all our news reports relating to children and families, visit the dedicated page on our website.

TB vaccine for infants

Heather Jaspan. © IAS/Deborah W. Campos - Commercialimage.net

The BCG vaccine against TB may increase the susceptibility of infants to infection with HIV, according to the results of a study.

The vaccine is routinely given at birth to children in countries with a high TB prevalence, for example South Africa.

But researchers in South Africa found that the vaccine also leads to increased activation of CD4 cells, the target for HIV.

The investigators believe that their findings could have implications for the BCG vaccination of children at risk of HIV, for instance those being breastfed by a mother with HIV.

HIV therapy for people taking anti-TB drugs

An 800mg daily dose of the integrase inhibitor raltegravir (Isentress) is a good alternative to the NNRTI efavirenz (Sustiva, also in Atripla) for people undergoing treatment for TB.
Therapy for TB works well in people with HIV, but there are interactions between some anti-HIV drugs and some of the drugs used to treat TB.
Earlier research had shown that an interaction between raltegravir and the key anti-TB drug rifampicin led to a reduction in raltegravir levels.
To overcome this interaction, researchers doubled the standard dose of raltegravir to 800mg each day.

They found that people treated with this dose were as likely as those taking HIV treatment based on efavirenz to suppress their viral load.

HIV and Stigma

Maria Ekstrand of the University of California San Francisco. © IAS/Deborah W. Campos - Commercialimage.net

A large number of healthcare workers stigmatise patients with HIV and have misconceptions about how the virus can be transmitted, several studies presented to the Washington conference show.

Research conducted in India revealed that 70% of healthcare workers blamed patients for their HIV infection, and that misconceptions about the risk of HIV transmission from routine contact were widespread.

Other research conducted in China also found that many healthcare workers stigmatised their HIV-positive patients. However, investigators also found that it was possible to effectively address this stigma through education.

Ugandan research also showed that it was possible to change the attitudes of healthcare workers for the better, especially alongside the rolling out of an HIV treatment programme. Healthcare workers were encouraged by seeing improvements in their patients’ health and realised it was no longer a ‘death sentence’.

Reducing HIV infections in injecting drug users

An image from the presentation of William Zule, illustrating how syringe design can affect the amount of blood collected and transmitted when sharing needles.

Delegates at the conference heard that it is possible to reduce the rate of new HIV infections in injecting drug users (IDUs).

Approximately 30% of all HIV infections are in injecting drug users. However, this population is often marginalised, stigmatised and criminalised. This can make prevention work with IDUs much harder.

Delegates heard that needle-exchange programmes can significantly reduce the sharing of syringes and needles.

In Tajikistan, this achieved a fall in new cases of hepatitis C and the stabilisation of HIV incidence. The cost-effectiveness of needle-exchange programmes was emphasised.

Nevertheless, a Chinese study showed that it was often difficult to retain drug users in methadone treatment programmes, often because of arrest.

Peer-support initiatives were found to have a positive effect on risk behaviour in Vietnam and Thailand.

There was also hope that a new type of syringe with less space for blood might help reduce the risk of transmission.

Integrase inhibitors go head to head

The experimental integrase inhibitor elvitegravir is equivalent to raltegravir (Isentress), the only approved drug in this class, new research shows.

A possible advantage of elvitegravir is that it is taken once daily. In contrast, raltegravir is one of the few antiretrovirals that needs to be taken twice a day.

Researchers compared the safety and effectiveness of the two drugs over two years. People in the study had previous experience of HIV treatment.

Rates of viral suppression were comparable, as were CD4 cell count increases and the frequency of side-effects.

HIV in female sex workers

Cheryl Overs, Monash University. © IAS/Steve Shapiro - Commercialimage.net

Researchers have found that female sex workers have 14 times the risk of having HIV compared to other women.

They looked at prevalence data from 50 countries and found that, compared to women of the same age, female sex workers were 14 times more likely to be infected with HIV.

But this is only a partial picture of the epidemic. There was no information on HIV prevalence in female sex workers for some countries with serious epidemics.

Researchers believe that their findings underline the importance of prevention initiatives targeted at sex workers. They calculated that these would not only protect the health of sex workers, but also cut HIV transmission rates by up to one third.

New boosting agent equivalent to Ritonavir

The new boosting drug cobicistat is equivalent to ritonavir (Norvir) when used to enhance levels of atazanavir (Reyataz), results of a study presented to the Washington conference show.

The potency of several anti-HIV drugs, including most protease inhibitors, is enhanced by taking a small boosting dose of the protease inhibitor ritonavir.

Until recently, ritonavir was the only available boosting agent.

However, a new drug called cobicistat has now been developed. Unlike ritonavir it has no activity against HIV.

Researchers compared the outcomes of people taking first-line HIV treatment based on atazanavir according to whether the protease inhibitor was taken in combination with cobicistat or ritonavir.

After 48 weeks of treatment, study participants taking the cobicistat booster were just as likely as those treated with ritonavir to have an undetectable viral load (85 vs 87%).

CD4 cell count increases were also comparable for the two agents, as was the frequency of side-effects.

Generic drugs could mean big savings for richer countries

Rochelle Walensky of Harvard Medical School. 

© IAS/Deborah W. Campos - Commercialimage.net

The use of generic drug formulations could reduce expenditure on HIV therapy in the US by $920 million each year, a new analysis shows.

A preferred first-line treatment option is Atripla (efavirenz combined with tenofovir and FTC). This is a patented medication.

However, the patent on efavirenz expires next year, as does the patent for 3TC (lamivudine, Epivir), which is similar to FTC (emtricitabine, Emtriva) in terms of efficacy and side-effects.

Researchers calculated that the use of generic forms of efavirenz and 3TC combined with tenofovir (Viread), could save $4000 per person per year, with a cumulative annual saving of $920 million.

The results of this analysis will be looked at with interest as the cost of treating HIV is a growing concern, even in richer countries.

A roadmap to changing HIV prevention

Nelly Mugo of the University of Nairobi. © IAS/Ryan Rayburn - Commercialimage.net

There were important discussions at the conference about the implementation of effective HIV prevention strategies.

In recent years there has been a wealth of dramatic data on the efficacy of new HIV prevention methods, including male circumcision, pre-exposure prophylaxis and treatment as prevention.

At a plenary session, delegates heard three key points for implementation – use data on new infections and prevalence to identify the populations most at risk; carefully choose and prioritize interventions that work in those populations; and deliver them at large enough scale to achieve high impact.

The global village

Images by Greta Hughson/aidsmap.com

The 19th International AIDS Conference (AIDS 2012) is not just the sum of its presentations and posters. Alongside the conference sessions, the exhibition halls and the global village have also been a hive of activity this week.

Join aidsmap’s Greta Hughson on a tour of the global village.

HIV and Hepatitis C

Vincent Lo Re of the University of Pennsylvania. 

Image ©Liz Highleyman / hivandhepatitis.com

People co-infected with HIV and hepatitis C continue to have a higher risk of serious liver disease than those who only have hepatitis C.

Researchers in the US compared rates of liver disease and liver-related death between co-infected and hepatitis C-monoinfected people.

Importantly, the co-infected participants were on HIV treatment, which has previously been shown to slow the progression of liver disease.

Co-infected people were at approximately twice the risk of developing decompensated liver disease and 69% more likely to progress to liver cancer.

An undetectable HIV viral load reduced the risk of liver disease, but even with HIV suppression outcomes were still poorer in co-infected people compared to those who only had hepatitis C.

HIV and the criminal law

Edwin J Bernard of the HIV Justice Network. 

© IAS/Ryan Rayburn - Commercialimage.net

Draconian laws on HIV transmission and exposure were the focus of a session at the International AIDS Conference.

Delegates heard that courts often dismissed evidence regarding the excellent prognosis of patients on HIV therapy and the impact of HIV treatment on the risk of transmission.

People with HIV are being imprisoned after sexual encounters when they did not disclose their status, even when no transmission occurred. In some instances, people had been prosecuted even though the type of sex they had engaged in involved no actual risk of HIV transmission.

More encouragingly, the session was also told that lobbying could lead to changes in the law.

For instance, Denmark suspended its tough HIV-specific laws after being presented with scientific evidence about the life expectancy of people on effective HIV therapy and the impact of treatment as prevention.

Access to treatment

Protester at the Say it loud! march in Washington. Image by Greta Hughson/aidsmap.com

Patents and intellectual property rights are still restricting access to antiretroviral therapy in middle- and low-income countries, the Washington conference was told.

The roll-out of antiretroviral therapy in poorer countries has been made possible in part due to the development of cheaper, generic formulations of a number of key anti-HIV drugs.

However, the maintenance of intellectual property rights means that medications needed for second- and third-line treatment remain prohibitively expensive. The conference also heard of the especially high cost of treatment for some middle-income countries.

Speakers at the session recommended that efforts were made to challenge patent applications to ensure access to treatment takes priority.

Retaining children in HIV care

Rene Ekpini of UNICEF. © IAS/Steve Shapiro - Commercialimage.net

On the same theme of keeping people in care, the Washington conference was told that three-quarters of children in need of HIV therapy are not receiving treatment, an unacceptable situation.

However, a variety of schemes show that this situation can be remedied.

One, implemented in Malawi, includes the provision of lifelong HIV treatment to all HIV-positive pregnant women, regardless of their CD4 cell count.

Another intervention in Zimbabwe has increased rates of diagnoses among children.

A number of practical measures – often with the local community playing a pivotal role – were also improving the retention of children in care.

These included:

• Use of community volunteers to accompany children to clinic appointments.
• Patient advocacy.
• Provision of transport vouchers.

Keeping people in HIV care

Images from the presentation of Dr Rachel Baggaley 

of the World Health Organisation.

Community-based support increases the likelihood that HIV-positive people will be retained in care, research conducted in South Africa shows.

Less than a third of people who start HIV therapy in southern Africa stay in HIV care. This is of serious concern. It means that the majority of people with HIV are not receiving the health benefits that come from specialist treatment and care. A high drop-out rate from care also seriously undermines the use of HIV treatment as prevention.

A speaker from the World Health Organization (WHO) presented findings from research in more than 20 countries about why people fall out of care at some point in the ‘cascade’ of HIV care (that is, the different stages of care from first being tested to being on effective treatment ). Reasons include the fear of stigma, denial about their condition, anxiety, poor links with the care available, inadequate clinic facilities and problems with travel.

But a South African study showed that providing community-based adherence support increased the chances that people starting HIV treatment would stay in care.

A new healthcare role of ‘patient advocates’ was introduced in 2004. These workers help support adherence and also provide counselling and psychosocial support.

Only 6% of people who had an advocate dropped out of care, compared to 10% of individuals who did not receive this kind of support.

Separate research showed that contact tracing could help reduce drop-out rates among children after starting HIV treatment.

Following the introduction of active contact tracing, rates of loss-to-follow-up were reduced from 22.7% to 8.5%.

The WHO report recommends the involvement of lay health workers to help ensure people move from one stage of the care ‘cascade’ to the next, and therefore stay in care.

HIV and TB

In other TB news, infection with HIV does not have an impact on the time taken to cure multidrug-resistant tuberculosis (MDR-TB), results of a study conducted in Botswana show.

TB is one of the most important causes of serious illness and death in people with HIV.

Strains of TB have emerged that are resistant to key drugs. Treatment for MDR-TB is more complicated than therapy for drug-sensitive TB and it also takes longer.

The results of the latest study show that therapy for MDR-TB has the same success rate in HIV-positive people as in people who are HIV negative.

In addition, the duration of treatment needed to achieve a cure did not differ by HIV status.

One year’s preventive therapy reduces the risk of TB in people on HIV treatment

Image: WHO/TBP/Gary Hampton

Twelve months of isoniazid (INH) preventive therapy (IPT) significantly reduced the incidence of all TB diagnoses in people with HIV who are also on antiretroviral therapy (ART), according to large randomised study conducted in Khayelitsha, South Africa.

“There was a 37% reduction in the rate of incident TB in the INH treatment group compared to those who were receiving ART alone,” said Dr Molebogeng Xheedhe Rangaka of the University of Cape Town, who presented the study findings.

This was a ‘late breaker’ at the conference and a full news story will be published on aidsmap tomorrow.

How long until a cure?

The panel at the HIV cure press conference. © IAS/Deborah W. Campos - Commercialimage.net

Some of the latest HIV cure research has been presented at International AIDS Conference this week.

Experts also met for a cure workshop prior to the conference, where they launched a global scientific strategy Towards an HIV Cure.

Research is looking at a range of different approaches to a possible cure, including:

• flushing out and destroying HIV lying dormant in ‘reservoirs’ in the body.
• stem cell treatment (like that which cured the ‘Berlin Patient’)
• starting HIV treatment very soon after infection – an approach that would only work for a small proportion of people with HIV.

It’s likely any successful cure process will involve a combination of approaches.

Promising results in some of the cure studies raise their own ethical questions, as people who are doing well on successful HIV treatment would have to stop to see if a functional cure has been achieved. An ethics working group has been set up to address these issues.

Steven Deeks, co-chair with Francois Barré-Sinoussi of the IAS HIV Cure working group, said: "The barriers to a cure are far greater than barriers to antiretroviral therapy [in the late 1980s]… Unless we get very lucky this is going to take well over a decade."

"The field is moving fast", said Sharon Lewin from Monash University in Melbourne. "We certainly don’t have a cure currently, but we have a better understanding of what we need to do."

Hormonal contraception and HIV risk

Contradictory evidence concerning the use of hormonal contraception and its possible impact on the risk of infection with HIV was presented to the International AIDS Conference.

Research published last year showed that women who used hormonal contraception had an increased risk of infection with HIV and were also more likely to transmit the virus.

A re-analysis of the results of this study confirmed the association between hormonal contraception and an increased risk of acquiring HIV.

The association between the use of hormonal contraception and HIV risk remained significant when taking into account rates of unprotected sex.

However, a meta-analysis of studies looking at the risk of HIV and the use of hormonal and non-hormonal forms of contraception failed to find any definitive evidence that hormonal contraception increased the chances of infection with HIV.

The point was made that access to reliable contraception is important for women, and that any possible HIV risk has to be balanced with the availability of effective contraception. 

reposted from AIDS 2012