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The TB burden in a community dropped as the uptake of antiretroviral treatment increased said Dr Francesca Conradie last night, referring to research by Karen Middelkoop from UCT.
Conradie, the clinical adviser to Sizwe Hospital, was reviewing the challenges of treating TB at the HIV Clinicians Society of Southern Africa meeting in Johannesburg.
One in 10 South Africans – rising to 2 in 10 in the Western Cape – would be infected by TB in their lifetime, she said at the start of her talk.
Conradie said if something looks like a duck, walks like a duck and quacks like a duck, it is probably was a duck. Ditto TB: clinicians usually knew what the symptoms looked like and should act on this promptly since delays killed patients with HIV.
Clinicians president Dr Francois Venter reported that 75% of patients in a new autopsy study at Johannesburg Hospital had TB.
“No HIV-infected person should die without the treatment of TB considered,” Conradie said.
She suggested that patients with AIDS and TB should started TB treatment and about a week later initiate ARVs, with the clinicians being prepared for IRIS.
IRIS – HIV-tuberculosis immune reconstitution inflammatory syndrome – is seldom fatal and could be treated though complications ,she said.
Conradie said, on average it takes 99 days for a confirmed TB diagnosis of an unemployed male patient.
She said that traditional healers were slightly faster than tertiary hospitals in picking up TB – GPs taking on average 10.5 days, traditional healers 21 days and tertiary hospitals 30 days. But these hospitals often had extremely complicated cases to treat, Conradie said in their defence.
Conradie reviewed the outdated microscopy and old TB drug in use. She reported, however, that three new drugs have been developed for drug-sensitive TB and that powerful drugs (like TMC207) were being tested for resistant strains and showing promising results.
Isoniazid Prevention Therapy (IPT) for all HIV-positive people should be started carefully and monitored carefully, she said, warning that drug resistance does develop.
TAC has been campaigning for IPT, on the ground that it reduces the risk of TB by just under 70% for people with HIV.
TB prevention studies were on the agenda at CROI 2010, which Conradie just attended.
Conradie recommended finding TB patients, particularly those with MDR-TB, more quickly and possibly treating them at home if they met certain criteria (eg stable accommodation).
By law in South Africa the state cannot constrain TB patients.
'Seek, test and treat to slow HIV'
“Studies in several nations show that treating people before they fall ill can curb the spread of disease,” writes Erika Check Hayden, in an article in the journal Nature this week.
Research in Africa, the US and Canada seems to provide more evidence in favour of “treatment as prevention”, Hayden reports.
* The African research involving seven countries and data from 3 408 discordant couples (Deborah Donnell) showed that “HIV-positive individuals who were receiving treatment almost never passed the virus on to their partner, whereas many untreated individuals did”.
* The American study found that “as ‘community viral load’ — the amount of virus in the blood of all HIV-infected individuals tested in San Francisco (Moupali Das) — declined from 2005 to 2008 because of drug treatment and increased awareness, the number of new infections in the city also dropped”.
* The Canadian study involving intravenous drug users had similar results, with new HIV infections dropping by around 50% when treatment was expanded to intravenous drug users with HIV throughout British Columbia(Julio Montaner).
But the results – presented at the annual Conference on Retroviruses and Opportunistic Infections in San Francisco, California – do not prove that antiretroviral treatment itself reduces the spread of HIV as there were many confounding factors.
Dr Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases, said in the article: “Rather than saying it’s an all-or-nothing phenomenon — that we’re going to eliminate the epidemic without anything else but test and treat — what I argue for is, why don’t we let test and treat be part of a more aggressive prevention armamentarium.”
One Love campaign urges people to talk about their sexual choices
Today the Treatment Action Campaign added their voices to those calling on President Jacob Zuma to show “leadership and responsibility for himself”.
TAC distanced itself from the clamour against Zuma, saying in its newsletter: “We do not want to impose moral judgements on people, especially on their private matters. Many of the responses to the President’s actions have been hysterical and self-righteous.”
“But the president is not just any person. People look to him to set an example,” TAC stated.
“In a country without a serious HIV epidemic, it might be arguable that his extra-marital affairs are for him and his family alone to resolve. But South Africa has the world’s largest HIV epidemic.
“The President holds the highest office in South Africa and therefore there are high expectations of him, as a leader, as an elder and as a role model.”
“The theme for World AIDS Day 2009 was ‘I am responsible, We are responsible, South Africa is taking responsibility’, TAC recalled.
“The message encourages individuals to reduce their number of sexual partners, for men and women to take responsibility by protect themselves and others, and to encourage consistent and correct condom usage.”
And this is the issue. How does Soul City – which is running creative HIV prevention campaigns – promote a “One Love” campaign when the man holding highest office has three wives and reportedly 20 children born out of wedlock.
“The president’s recent actions undermine all of who are really trying to meet the prevention target of reducing HIV transmission by 50%,” stated TAC.
“The message of responsibility – agreed upon by civil society and government – applies to all of us including our highest leaders.”
Zuma is right when he says South Africa needs to debate its “moral code”.
But he is mistaken if he thinks the criticism against him is in fact an attack on traditional culture.
He said that it was unconstitutional to use one own’s culture to judge others, adding: “Some of the traditions are being rubbished; called names, they’re backward; and we keep quiet.”
Mr President, this is not about what is culturally or morally acceptable. This debate is about what is acceptable presidential conduct in South Africa – a country with the highest numbers of people with HIV in the world.
Herpes simplex virus
Daily treatment with aciclovir for people with both HIV-1 and herpes simplex virus type 2 (HSV2) lowered their risk of progression by 16%.
People with HIV often have genital herpes (HSV2).
3381 heterosexual people who were infected with both HSV2 and HIV-1 were enrolled in the trial at 14 sites in Africa.
The volunteers were “randomly assigned in a 1:1 ratio to aciclovir 400 mg orally twice daily or placebo, and were followed up for up to 24 months”.
“Aciclovir reduced risk of HIV-1 disease progression by 16%,” the researchers found, recommending further consideration of the “role of suppression of herpes simplex virus type 2 in reduction of HIV-1 disease progression before initiation of antiretroviral therapy”.
The treatment did not reduce the risk of HIV transmission.
Popular singer Nadja Benaissa charged after sex with men
In Germany, it’s a criminal act to have sex with people without telling them you are HIV positive.
Now singer Nadja Benaissa, from that country’s popular girl band No Angels, has been charged with “causing bodily harm for failing to inform sexual partners” that she was HIV positive.
One of the three people involved in this case has since become infected with virus.
Prosecutors from Darmstadt, a town near Frankfurt, said: “She was well aware that any unprotected sexual contact can lead to the virus being passed on.”
Benaissa was arrested last year April before a performance in Frankfurt, on the “suspicion of sleeping with the men” between 2004 and 2006.
She faces up to 10 years in jail if found guilty of this offence.
Of course it’s immoral and unethical to knowingly put another person at risk, but in this case Benaissa is being held soley responsible for this new HIV infection.
What about the responsibility of her adult sexual partners: why didn’t they use condoms to protect themselves in an era when HIV is common?
Criminalising the sexual behaviour of consenting adults with or without HIV will worsen the stigma around this virus.
In South Africa, all sexual partners need to think about HIV and the risks of infection. A Cape Town survey of 24 HIV-positive men and 58 HIV-positive women found that most sex – 80% of 5000 sex acts – involved no condoms at all.
“More than half of the unprotected sex events were with HIV -negative partners or partners with unknown HIV status,” said the researchers, who were led by Dr Susan Kiene and Dr Leickness Simbayi.
Another study of HIV risk among 15- to 24-year-old females and their older male partners, or “sugar daddies”, found both parties wrongly believed the other to be at low risk for HIV .
It’s time for every sexually active person to be responsible for himself or herself.
VIVA GLAM for charity
The cosmetic house M.A.C established an HIV/AIDS fund in 1994 and all sales from the Viva Glam Cyndi and Viva Glam Gaga lipsticks will go to this fund, which operates globally.
Obviously M.A.C. will also benefit from this initiative, but at least its AIDS fund has a strong track record of training, here in South Africa.
Lauper and Gaga are the latest performers whose celeb status is being used to fight the HIV epidemic.
Last night Gaga wore hundreds of pearls, including pasted on her body, to a gala raising money for HIV/AIDS work.
Babies, children and adolescents get HIV care from ECHO services
Nearly half the teenagers admitted to two hospitals in Harare in Zimbabwe were infected with HIV and the virus was the most common cause of in-hospital death among them, a new study shows.
Adult opportunistic infections and chronic paediatric HIV/AIDS complications were the most common cause for their admission.
Many of them were likely to have a mother who was HIV-positive or who had died of AIDS but they had survived into older childhood.
Now they need “better recognition” and care, Rashida Ferrand and his co-authors stated.
Wits HIV expert, Professor Glenda Gray, supported this call, stating in the same journal: “There is an urgent need for services that will be able to provide accessible and appropriate HIV testing, counselling, and support, as well as facilitate access to ART and appropriate sexual risk-reduction interventions.
“The adolescents admitted to hospitals in Harare could have benefited from early diagnosis and concomitant initiation of ART, and this absence of treatment should not continue to be the plight of similar adolescents in our region.”
In South Africa as many as half a million children are estimated to have HIV.
Dr Marnie Vujovic, a clinical psychologist for Wits Paediatric HIV Clinics, said that sensitive and age-appropriate disclosure to adolescents born with HIV was critical to their physical, mental and social wellbeing – and to avoid them finding out by accident.
“Disclosure to children is the biggest issue in our caregiver support groups and a problem at all sites,” she said.
Cracking the integrase crystal mystery after 20 years
Scientists have succeeded in growing a crystal that reveals the structure of the enzyme, integrase, and this could improve the design of the integrase inhibiting drugs commonly used for AIDS treatment.
Integrase – an enzyme found in retroviruses like HIV – plays a key role in HIV infection.
“When HIV infects someone, it uses integrase to paste a copy of its genetic information into their DNA,” the researchers from Imperial College in London stated.
“Availability of the integrase structure means that researchers can begin to fully understand how existing drugs that inhibit integrase are working, how they might be improved, and how to stop HIV developing resistance to them.”
Many researchers had tried and failed for more than 20 years “to work out the three-dimensional structure of integrase bound to viral DNA”, prior to this study, they stated.
To grow a crystal of “sufficient quality to allow determination of the three-dimensional structure”, the scientists from Imperial College in London and Harvard University in Boston conducted more than 40 000 trials.
These results in seven kinds of crystals, only one of which was of high enough quality for their study.
Lead author Dr Peter Cherepanov said: “We went back to square one and started by looking for a better model of HIV integrase, which could be more amenable for crystallization.
“Despite initially painstakingly slow progress and very many failed attempts, we did not give up and our effort was finally rewarded.”
Their findings are published this week in the journal Nature.
