I told a few friends the other day that I was worried that I was turning into a shrieking harpy. There is no doubt that I have been horribly angry for the past 15 years. I have watched the AIDS epidemic flourish, mow down friends, family and colleagues, and, despite the vast sums of money and hives of activity devoted to combating the disease, new infections erupt in the millions and millions more die horrible, painful deaths each year.
The Retrovirus Conference is the most important scientific meeting on HIV of the year. This year's conference, the 13th, was held in Denver in early February 2006. Most presentations were aimed at scientists actively working on HIV basic science, clinical science, or drug development. But a group of leading HIV researchers organized a special session designed to acquaint younger scientists with some of the critical unanswered questions about HIV and to entice them into making HIV their career. AIDS research has made amazing strides in the 25 years since it was first described in the medical literature. The disease has gone from being a death sentence to being a mostly manageable condition for those with access to anti-HIV drugs.
Still HIV is no picnic, and worldwide, millions of people with AIDS will die this year. It's clear that there is much work to be done in HIV research. It's also clear that it may be 10 or 20 years before some of the most important scientific goals, such as a vaccine or achieving immune control of the virus, are accomplished. The quest for a cure may take much longer.
Recently, the FDA blood products advisory committee has been considering what the agency should know before approving an over-the-counter (OTC) rapid home test to diagnose HIV infection.
At the 12th Annual Retrovirus Conference held in Denver earlier this year, a poster authored by Karen Beckerman and coworkers presented findings from an analysis of central nervous system birth defects that found no increase in the rate of birth defects in babies born to mothers taking antiretroviral (ARV) drugs during pregnancy compared to babies from the general population.
In an important proof of concept study presented at the 12th Annual Retrovirus Conference, Nicolas Nagot and colleagues from London School of Hygiene and Tropical Medicine, investigated whether suppressive treatment for herpes simplex virus (HSV) associated with genital herpes could have an impact on HIV transmission.1
Who are the elite controllers? No, they're not initiates of Yale's secretive Skull and Bones Society or members the Trilateral Commission. Elite controllers are people infected with HIV who have been able to suppress their virus without using antiretroviral medications. And Dr. Bruce Walker of Boston wants to meet them and find out how they do it.
GMHC Treatment Issues: September / October / November - Volume 19, Number 9, 10 & 11
There is something Old World about the biannual European AIDS Conference. The two I have attended were held in cold, northern towns where fuels like peat and coal are still used to heat rooms. This year's meeting, in Dublin, Ireland, was sponsored by the European AIDS Clinical Society (EACS) and offered two full days of scientific talks and poster presentations to doctors and researchers from around the continent. But unlike the Annual Retrovirus Conference in the US, which primarily attracts scientists and physicians with a strong interest in research, the European conference is also attended by a substantial number of everyday, working clinicians who come to get a refresher course in state-of-the-art HIV care.
Nicolai Lohse and colleagues from Odense University Hospital in Denmark have been analyzing patient records from Denmark's HIV Cohort, a nation-wide study of nearly every person on antiretroviral (ARV) therapy in that country. They have previously reported that virologic failure among patients who first started triple combination ARV therapy before 1999 was far more common than in those who began therapy after 1999. This finding is probably due to the advanced stage of disease in the earlier group, and due to preexisting NRTI resistance caused by prior use of one- and two-drug regimens.
Dr. Joseph Sonnabend was one of the earliest AIDS clinicians and researchers. He helped introduce the concept of safer sex and was a pioneer in establishing community-based research. He was mentor to many of the first generation of AIDS activists and is famous among patients for being the first doctor who treated them as equals. He recently retired from medical practice in New York and now lives in London.
There is an open question about how to monitor antiretroviral (ARV) therapy in the developing world. In rich countries, HIV RNA and CD4+ cell counts are routine. RNA tells the amount of virus detectable in the blood, and it gives a rapid readout on the success of therapy. CD4 count tells about the health of the immune system and usually responds in a positive direction after a period of successful ARV treatment. These tests and others are routinely done before starting therapy and every few months thereafter. They are performed in central laboratories and cost hundreds or thousands per year.
GMHC Treatment Issues: July / August - Volume 19, Number 7 & 8
It was a comment heard again and again from speakers at the podium and attendees in the corridors of the First National Conference on Methamphetamine, HIV, and Hepatitis. In mid-August 2005, over 900 people jammed into the cramped meeting rooms of a Salt Lake City hotel to attend the event sponsored by the Harm Reduction Project of Salt Lake City and the Harm Reduction Coalition of New York City.
Right now there is no silver bullet for treating meth dependency, but most places are using cognitive behavioral therapy and motivational interviewing.
The Drug Enforcement Agency (DEA) maintains fact sheets on recent patterns of illegal drug sales and use in each state. Here are a few selected reports concerning methamphetamine that illustrate the diversity of sources for the drug.
A field of dreams was built and the people came. The precursor to the First National Conference on Methamphetamine, HIV, and Hepatitis was the perplexing problem of a drug that has been harrying the hinterland for the past decade or longer. Our initial goal was to draw maybe 300 people, but that was a gross underestimation of how this event was desperately needed. When we announced the conference, everyone wanted in, including the Federal government: Health and Human Services (HHS), the Centers for Disease Control (CDC), the Drug Enforcement Administration (DEA) and National Institute on Drug Abuse (NIDA). Utah Senator Orrin Hatch supplied a letter of support for the event that was instrumental in drawing in local health departments, many of which sent attendees and speakers and also lent their imprimatur to the conference.
GMHC Treatment Issues: May / June - Volume 19, Number 5 & 6
Human papillomavirus (HPV) is many things to many people. As an infection of the skin, some varieties of HPV can cause annoying warts on the hands or feet, while other varieties of HPV infect the mucosa of the genitals and can cause warts or worse there.
One lesson from all of this is that the bar for acceptable toxicity and efficacy is now set much higher, and drugs that looked promising in 1999 won't cut it in 2006 and beyond. Now, if we could only get rid of ritonavir boosting.
These are condensed excerpts from discussions by the FDA Antiviral Advisory Committee on the new drug application for Aptivus (tipranavir) 250mg capsules indicated for treatment of patients with HIV.
The 2005 HIV vaccines and pathogenesis Keystone Symposia, took place in Banff, Canada in early April 2005. This latest unveiling of cutting edge research in HIV vaccine developments and pathogenesis was set high in the alpine landscape of the Alberta Rocky mountains at the grand Banff Fairmont Springs hotel, a location that brought images of Jack Nicholson to mind.
A Danish musician from the sixties wrote a song about Kathmandu: "The streets are made of rubber take off your shoes and walk on them." In a present day Kathmandu if you take off your shoes there is a chance that you will get pricked by a needle. Over 70% of drug users living in this historic city are infected with HIV. However this neither rings an alarm for the government nor for the development partners working in Nepal.
The Centers for Disease Control (CDC) made headlines in June by presenting new estimates that over a million people in the U.S. are HIV-positive. Coverage of the National HIV Prevention Conference focused heavily on two overlapping groups men who have sex with men, and African-American men and women who collectively account for the majority of new infections. Injection drug use was virtually absent in media accounts, reflecting a broader marginalization of IDUs in current HIV prevention discussions.
GMHC Treatment Issues: March / April - Volume 19, Number 3 & 4
HIV-related lipoatrophy (fat loss under the skin) is a clinical problem that affects many people living with HIV. Lipoatrophy can cause substantial loss of buttock tissue, veiny legs and arms, and facial wasting. Lipoatrophy can happen alone or in combination with lipohypertrophy (fat accumulation) in the visceral (organ) and dorsocervical (back of the neck) area. These body changes, with or without blood level alterations of cholesterol, triglycerides, lactic acid, glucose, and insulin, is called HIV-related lipodystrophy syndrome.
Against all odds, treatment for HIV is expanding in Africa and elsewhere in the developing world. Beginning in the late 1990s, Brazil showed the way by making affordable generic antiretroviral (ARV) drugs produced in their own factories available to all of its HIV-positive citizens. By daring to break the monopoly of the multinational patent holder companies, Brazil dropped the average price of a year's therapy from $10,000 to under $600 and made it available for free to 140,000 Brazilians. India's historically flexible patent laws allowed generic drug makers there to export affordable drugs to Africa, where non-governmental (NGO) treatment programs run by organizations like Doctors Without Borders (MSF) soon proved that providing HIV treatment in severely resource-limited settings was feasible and therefore conceivable for African governments to undertake.
In January 2005, an unprecedented meeting was held in Mumbai, India, between four manufacturers of affordable generic antiretroviral medicines and 30 advocates for HIV treatment access drawn from every region of the world. This was the second meeting of a worldwide HIV community advisory board (CAB) with drug companies; the first was held in San Francisco in 2004 with several multinational pharmaceutical firms. The meetings were organized by iBase of London and GMHC.
Many AIDS activists have been enraged by the export abroad of conservative American morality on sex, drugs and prostitution through HIV/AIDS programs funded by the U.S. government. Particularly galling is that it replaces accepted, evidence-based public health policies with ideology. But if there is one thing this U.S. government hates more than fags, junkies, hookers, condoms and clean needles, it's socialized medicine.
A group of HIV/AIDS community doctors and organization leaders gathered at the New York City Department of Health and Mental Hygiene on a Friday morning in early February 2005. They had been summoned by Health Commissioner Thomas Frieden to attend a press conference about a newly diagnosed strain of HIV. In a briefing to the group before the press was ushered in, the commissioner explained that a gay New Yorker in his 40s had become infected in October 2004 after bingeing on crystal methamphetamine and having sex with hundreds of people over a period of several months.
In the United States, recent media attention about a multi-drug resistant HIV (the "super-bug") couldn't come at a worse time when HIV prevention efforts are both increasingly censored and under funded. Unfortunately, many public health officials are currently relying on a one-size-fits-all approach to preventing further transmission of HIV. Abstinence is promoted over more comprehensive sex education approaches that address contextual as well as individual level factors. There is plenty of research showing the strong link between important contextual factors HIV/AIDS stigma, homophobia, class, racism, community cohesion, depression, substance use, etc and individual level HIV risk.
The Journal of Urban Health recently released an advanced access version of a special issue devoted to investigations of substance use and sexual risk behavior among men who have sex with men (MSM). Some of these papers may offer useful insights for designing interventions and understanding the complex motivations that drives high risk behavior and continuing HIV transmissions in what is often referred to as a "community" but are, as is evident from these studies, highly diverse populations of individuals with many differing motivations and behavior patterns.
The UNAIDS report on the HIV/AIDS pandemic highlights the growing rates of infection among women worldwide. Women now account for nearly 50% of all individuals living with HIV/AIDS worldwide. However, in Africa, the situation is more ominous. Almost 57% of all individuals living with HIV/AIDS in Africa are women. For Africans ages 15-24 living with HIV/AIDS, women account for 76% of all infections. In South Africa, Zambia and Zimbabwe, young women ages 15-24 have rates of infection that are between three and six times that of their male peers. The so called feminization of AIDS appears to be in full swing in Africa.
The Conference on Retroviruses and Opportunistic Infections (CROI) is the most important AIDS science meeting of the year. The conference organizers run a tight ship with attendance limited to working scientists and a sprinkling of community members involved with treatment advocacy and education. It is not a trade show and there are no pharmaceutical company pavilions, free pens or slick sales pitches at CROI.
It's official: Superbug fatigue has set in. Nobody held a press conference, but the case report that launched a thousand news articles, watercooler conversations, and heated e-mail exchanges has passed from the acute phase into the chronic fate of overhyped AIDS stories: after a shiver of anxiety, a collective shrug of indifference.
This information is designed to support, not replace, the relationship that exists between you and your doctor.