The Rx Coles Notes 

Hepatitis C epidemic among young people comes as surprise

"What's happening is we have 16-, 17- and 18-year-olds that are addicted to heroin, and the majority of them started with prescription drugs,"......Newly reported probable and confirmed hepatitis C infections in Massachusetts 15-to-24-year-olds rose from 65 to 102 cases per 100,000 within the span of four years.....from 2002-06, the state saw an overall decline in new hepatitis C reports from 181 to 128 per 100,000.....we could easily see, within that same grouping, HIV transmission"

HCV/Heroin Epidemic in Youth Nationwide - (05/07/11)

Need to know:

A wave of youth exposure to Hepatitis C, a virus that affects the liver, and is transmitted similarly to HIV (i.e. blood-to-blood transmission) but is much more infectious, is on the rise within the youth population in Massachusetts.

During the period documented, overall number of new cases went down in the States, but with the youth percentage going up.

This appears to be due to a growing trend for youth to be using pharmaceutical drugs such as Oxycodone (Oxycotin) and other heroin-like drugs. Infections can occur easily with injection drug use and shared needles, unprotected sex (although the incidence of sexually transmitted Hep C is more common among gay men), and sharing straws for nasal inhalation.

From the article:

But "the current hypothesis that we're testing ... is that many of these cases are in people who start with prescription drugs like OxyContin, oxycodone and then progress to injecting either those drugs or heroin, and using injection drug equipment that they share with other people," he said.

An interesting point was that the trend included youth from urban, suburban, and rural areas of the state.

The good news is that HIV infection is not increasing in the same way, but the risks are there when drug equipment sharing is involved.

Public health has let this slip by under the radar. It will be interesting to see if this trend occurs in other states, or even Canada for that matter.

Article: Patient No More 

When follow up research on Timothy Brown, formerly known as the “Berlin Patient”, showed he was still HIV-free after a ground-breaking stem cell transplant, why did Time Magazine name PReP (taking medications to prevent infecting a sexual partner) as a medical break through?

We have been conditioned to believe HIV is a “chronic & manageable” illness. Little discussion has occurred on curative research. 

The Coles Notes:

First, why not curative research, and the lack of discussion of it. It feels as if the research community has bought into the belief that HIV is not a curable illness, and that we can live with a chronic manageable status. Unfortunately that is not good enough. These medications can be toxic over the long term. We are still guinea pigs when it comes to their long term use.

This is not to scare people away from taking HIV medications. It is important to take them if it is appropriate for you. The silver lining is that the side effects are far less than when they first came out. Taking medications does not mean “the next step” to getting sick, but rather preserving your immune system in the healthiest state for the time when we do find either even better treatment methods, or a cure.

Timothy was sick with a type of cancer called acute myeloid leukemia (AML) which required a stem-cell transplant.

Stem-cells are the precursor cells that divide into other types of cells. The process of a stem-cell transplant is not an easy one. The immune system has to be taken away so the body will not reject these foreign cells risking infection or worse.

Timothy underwent two stem-cell transplants. The treating physician sought out stem cells from a donor who had immune system cells that HIV could not infect and then replicate.

HIV needs to grab onto two spots on a specific kind of immune cell. The genetic alteration of the donor’s immune cells produced cells without one of these places HIV needs to get a hold of in order to get into the cell.

If HIV can’t get into the cell, then it can not replicate.

This is not an easy procedure and it has taken a long time for Mr. Brown to recover. There are practical questions on whether this procedure should be performed on HIV positive individuals without immediate life-threatening illnesses such as Leukemia.  This is not to mention the cost of $250,000.

Three-and-a-half years later Mr Brown remains off  HIV medication, and there is no HIV to be found in his body.

The unthinkable has happened, the eradication of HIV. There is still much to learn.

We need to stay focused on curative research and not give up on it. We need more than just a manageable chronic disease label.

For more discussion on curative research check out Devan Nambiar's articles. linked below

Washington, DC  May 11, 2011 - Men and women infected with HIV reduced the risk of transmitting the virus to their sexual partners through initiation of oral antiretroviral therapy (ART), according to findings from a large multinational clinical study conducted by the HIV Prevention Trials Network (HPTN), a global partnership dedicated to reducing the transmission of HIV through cutting-edge biomedical, behavioral, and structural interventions

The study, known as HPTN 052, was designed to evaluate whether immediate versus delayed use of ART by HIV-infected individuals would reduce transmission of HIV to their HIV-uninfected partners and potentially benefit the HIV-infected individual as well. Findings from the study were reviewed by an independent Data and Safety Monitoring Board (DSMB).The DSMB recommended that the results be released as soon as possible and that the findings be shared with study participants and investigators.

The DSMB concluded that initiation of ART by HIV-infected individuals substantially protected their HIV-uninfected sexual partners from acquiring HIV infection, with a 96 percent reduction in risk of HIV transmission.

HPTN 052 is the first randomized clinical trial to show that treating an HIV-infected individual with ART can reduce the risk of sexual transmission of HIV to an uninfected partner.

“This is excellent news,” said Dr. Myron Cohen, HPTN 052 Principal Investigator and Associate Vice Chancellor for Global Health and Director of the Institute of Global Health and Infectious Diseases at the University of North Carolina at Chapel Hill. “The study was designed to evaluate the benefit to the sexual partner as well as the benefit to the HIV-infected person. This is the first randomized clinical trial to definitively indicate that an HIV-infected individual can reduce sexual transmission of HIV to an uninfected partner by beginning antiretroviral therapy sooner. HPTN recognizes the significant contribution that this study’s participants have made to furthering the progress in HIV treatment and prevention. We are very grateful for their participation.”

HPTN 052 began in April 2005 and enrolled 1,763 HIV-serodiscordant couples (couples that have one member who is HIV-infected and the other who is HIV-uninfected), the vast majority of which (97 percent) were heterosexual. The study was conducted at 13 sites across Africa, Asia and the Americas. The HIV-infected person was required to have a CD4 cell count between 350-550 per cubic millimeter (cells/mm3) at enrollment, and therefore did not require HIV treatment for his or her own health. Couples were randomized to one of two groups. In one group, the HIV-infected person immediately began taking ART (immediate ART group). In the other group, the HIV-infected person began ART when his or her CD4 cell count fell below 250 cells/mm³ or if he/she developed an AIDS-related illness (the delayed ART group).

Throughout the study, both groups received HIV-related care that included counselling on safe sex practices, free condoms, treatment for sexually transmitted infections, regular HIV testing, and frequent evaluation and treatment for any complications related to HIV infection. Each group received the same amount of care and counselling.

Any HIV-uninfected person who became HIV-infected during the course of the study was referred to local services for appropriate medical care and treatment.

“This rigorously conducted clinical trial demonstrates that ART dramatically reduces HIV transmission from an infected partner to an uninfected spouse or partner,” states Sten Vermund, HPTN Principal Investigator and Amos Christie Chair of Global Health at the Vanderbilt University School of Medicine. “Earlier therapy is a superior option that benefits both an infected individual and his or her uninfected partner and we support global efforts to offer ART to everyone who needs it.”

 “Previous data about the potential value of antiretrovirals in making HIV-infected individuals less infectious to their sexual partners came largely from observational and epidemiological studies,” said NIAID Director Anthony S. Fauci, M.D. “This new finding convincingly demonstrates that treating the infected individual — and doing so sooner rather than later — can have a major impact on reducing HIV transmission.”

“The HPTN 052 study provides compelling evidence for a new HIV prevention approach that links prevention and care efforts,” said Quarraisha Abdool Karim, HPTN co-principal investigator and associate scientific director of CAPRISA. “Strategies for scaling up knowledge of HIV status and increasing treatment coverage are critical next steps to realizing the public health benefits of this finding. This is also very good news for women who bear a disproportionate burden of HIV infection acquired from infected male partners but have few options to reduce their risk especially if their partner refuses to use condoms consistently.”

This email comes from Emma Ruby-Sachs - Avaaz.org This email address is being protected from spambots. You need JavaScript enabled to view it.  

Dear friends,

It's monstrous -- thousands of Ugandans could face the death penalty -- just for being gay. On Wednesday, Parliament may pass a law that punishes homosexuality with death – we have 48 hours to act.

We've stopped this bill before, and we can do it again. Ugandan President Museveni is scared of losing valuable international aid from the West -- after a massive international outcry last year, he stopped the bill from coming to a vote. But political unrest is mounting in Uganda, and religious extremists in Parliament are hoping confusion and violence in the streets will distract the international community from a second push to pass this hate-filled law. We can show them that the world is still watching. If we block the vote for two more days until Parliament closes, the bill will expire forever.

With 48 hours to go, every moment counts. Over half a million of us have already joined the call -- let’s get to one million voices against Uganda's gay death penalty in the next 48 hours -- click here to take action, then forward this email to everyone:

http://www.avaaz.org/en/uganda_stop_homophobia_petition/?vl

For Frank and thousands of others, being gay in Uganda is already dangerous and terrifying. They are regularly harassed and beaten, and just months ago, Avaaz colleague and gay rights activist, David Kato (pictured above), was brutally murdered in his own home. Now LGBT Ugandans are threatened by this draconian law which imposes life imprisonment for people convicted of same-sex relations and the death penalty for “serial offenders”. Even NGOs working to prevent the spread of HIV can be imprisoned for “promoting homosexuality” under this hate-filled law. 

Right now, Uganda is in political turmoil -- in the wake of the Arab spring, Ugandans across the country are taking to the streets, protesting high food and gas prices. President Museveni has responded by violently cracking down on the opposition. This upheaval has provided religious extremists in Parliament the perfect chance to slip in the shelved anti-gay bill just days before Parliament closes and all proposed laws are wiped from the books.

Museveni backed away from this bill last year after Obama called it an 'odious' law and international pressure threatened Uganda's aid and support. With violent protests sweeping the streets, Museveni ismore vulnerable than ever. In the next 48 hours, let’s build a massive international outcry in support of respect for human rights, justice and tolerance and against the anti-gay death penalty law. Together we can save lives by stopping this bill -- sign below, then tell friends and family:

http://www.avaaz.org/en/uganda_stop_homophobia_petition/?vl

Earlier this year, we stood in solidarity with Uganda's equality movement to show that every human life, no matter what creed, nationality or sexual orientation, is equally precious. Our international petition condemning the gay death penalty law was delivered to Parliament – spurring a global news story and enough pressure to block the bill for months. When a tabloid newspaper published 100 names, pictures and addresses, of suspected gays and those identified were threatened, Avaaz supported a legal case against the paper and we won! Our community has funded security for gay rights activists and operational funding for gay rights organizations. Together we have stood up, time and time again, forUganda’s gay community -- now they need us more than ever. 

With hope and determination, 

Emma, Iain, Alice, Morgan, Brianna and the rest of the Avaaz team 


SOURCES: 

Ugandan lawmakers hold hearings on anti-gay bill
http://www.google.com/hostednews/ap/article

Uganda gay activist Kasha Jacqueline Nabagesera hailed
http://www.bbc.co.uk/news/world-africa-13278374

Pulling Out All the Stops to Push an Antigay Bill
http://www.nytimes.com/2011/04/14/world/africa/14uganda.html

The Ontario Working Group on Criminal Law and HIV Exposure is inviting people to complete a confidential on-line survey on prosecutorial guidelines for Ontario criminal cases involving allegations of HIV non-disclosure.  The survey is part of the Campaign for Prosecutorial Guidelines in Ontario.

We want your valuable input on what to include in our recommendations to the Ontario Attorney General.  If you are interested in the criminalization of HIV non-disclosure and helping us make recommendations that will restrict prosecutions in Ontario, we want to hear from you.  It will take approximately 20 minutes to complete the survey.

Here is the link to the survey.  

Please complete the survey by 17 May 2011 at 7:00 pm.  We apologize for the quick turn-around time, but we need to get our recommendations to the Attorney General by the end of May.

Please alert friends and colleagues in Ontario who are interested and engaged in the issue of criminalization of HIV non-disclosure.

Thanks in advance.

Ryan Peck, Executive Director, HIV & AIDS Legal Clinic (Ontario), Co-chair, Ontario Working Group on Criminal Law and HIV Exposure

Anne-Marie DiCenso, Executive Director, PASAN, Co-chair, Ontario Working Group on Criminal Law and HIV Exposure

Go here for more information about the Ontario Working Group on Criminal Law and HIV Exposure and the Campaign for Prosecutorial Guidelines.

In a recent editorial, Dr. Mitchell Katz, a physician with extensive experience in treating patients with HIV and AIDS, argues that HIV/AIDS care should shift from HIV specialists to primary care physicians now that, in his opinion, HIV is essentially a chronic, treatable disease. The editorial comes several weeks after an Institute of Medicine report warned of serious and growing shortages in the HIV healthcare system and also recommended shifting more HIV care to primary care doctors.

“If specialty care is less needed than it used to be for HIV-infected patients, it turns out that primary care is more needed. Owing to the advances in HIV treatment, our patients are no longer dying: they are aging!” wrote Dr. Katz, director of the Los Angeles Department of Health Services.

Dr. Katz argued in the editorial that HIV is now largely a chronic disease with relatively routine care that could be provided by primary care physicians, as is the case with diabetes.

Most people with HIV now begin treatment with Atripla (efavirenz/emtricitabine/tenofovir), a once-daily pill containing three antiretrovirals that has simplified HIV treatment. In addition, viral load testing – which measures the amount of HIV in the blood and allows physicians to measure how effective HV treatment is – has become fairly routine.

Dr. Katz argued that with the newer drugs and monitoring abilities, patients with effectively suppressed viruses are unlikely to develop the opportunistic diseases that made HIV treatment so difficult in the 1980s and 1990s.

“The most common reason for a patient’s condition not being fully suppressed while receiving one of the conventional regimens is non-adherence, a primary care problem if ever there was one,” wrote Dr. Katz.

“The small percentage of patients who do not obtain a good response to a conventional regimen despite being adherent will need referral for specialty care,” he added.

Instead, the primary challenges faced by people with HIV are increasingly caused by other conditions, such as heart disease, bone loss, and other problems – issues which, according to Dr. Katz, are best dealt with by a primary care physician.

Primary Care Physicians May Fill In Gaps Left By Dwindling Numbers Of HIV Specialists

The Institute of Medicine (IOM) report, published last month, also recommended shifting more HIV care to primary care doctors, stating that decreasing numbers of HIV specialists, along with a growing HIV-positive population, are placing strains on the current United States healthcare system.

In addition, people with HIV are increasingly moving from urban centers to more rural areas where HIV-care providers are especially scarce.

The authors recommended that primary care physicians receive better training in caring for people with HIV and that medical students receive greater exposure to outpatient HIV care throughout school and post-graduate training.

Kathryn Hafford, a registered nurse and director of the Division of Disease Prevention of Virginia’s Department of Health, said in correspondence with the AIDS Beacon that fewer medical students are choosing to specialize in HIV care.

“The health care system is strained and does not have enough qualified providers to increase HIV testing and ensure availability of medical care. Older HIV physicians are leaving the field faster than new physicians are entering,” said Hafford, who was not involved with the report. “Physicians are often not choosing infectious diseases because they can make substantially more money in other specialties,” she added.

She agreed with the IOM that more training for primary care physicians is needed. “Providing increased awareness of HIV in curricula, as well as encouraging students to pursue primary care and HIV specialization could make a significant difference in the availability and quality of care,” she said.

“Faculty need to make sure students consider HIV when working with patients with other health issues because less media publicity, improved treatment regimens, and focus on HIV in developing countries have resulted in some people thinking HIV is no longer a problem in the U.S.,” she added.