HIV/AIDS

More news from the International AIDS Conference: Stanford researchers have presented findings showing that family planning counseling could be a cost-effective way to help minimize the number of children born HIV-positive in sub-Saharan Africa. The study involved 98 HIV-positive women – two-thirds of whom attended three 90-minute group courses on family planning, sexual negotiation, and self-esteem building. My colleague Ruthann Richter, who has been reporting from the conference, writes:

According to [Clea Sarnquist, DrPH, MPH, a senior research scholar in pediatrics] and her colleagues, about 40 percent of pregnancies in sub-Saharan Africa are unplanned. Such unwanted pregnancies could be prevented if women relied on long-acting forms of contraception — such as the intra-uterine device, or IUD, or hormonal implants — rather than birth control pills or diaphragms. Indeed, the researchers found that [three months] after receiving group counseling almost 90 percent of the HIV-positive women in the study chose a long-acting form of contraception.

The women in the study, which was conducted in a suburban region of Zimbabwe, also said they felt a greater sense of power in negotiating sexual activity, including condom use, and were more open with their partners about their HIV status, the researchers reported.

Sarnquist, who is hoping to expand the study to a larger population of women who could be followed over a longer period of time, said of the significance of this work, “If you can help prevent HIV-positive women from having unplanned children, obviously you’re going to prevent unnecessary HIV transmission.”

Previously: International AIDS Conference Day Four: Focusing on a vaccine, International AIDS Conference Day Three: Daring to talk about a cure, International AIDS Conference Day Two: Hillary Clinton envisions AIDS-free generation, International AIDS Conference: Day One, WHO’s new recommendations on contraceptive use and HIV and New book shows the pain and hope of AIDS orphans

Less than 10 years ago, I remember hearing French virologist Francoise Barre-Sinoussi, PhD, winner of a Nobel Prize for co-discovering the virus, express deep pessimism about whether it would be possible to develop an AIDS vaccine, the holy grail of the epidemic.

But as Barton Haynes, MD, director of the Duke Human Vaccine Institute, said at the International AIDS Conference today, the field of vaccine research is enjoying a revival, with hopes renewed, thanks to a series of new developments in just the last few years.

“I can assure you the HIV vaccine field is invigorated. We are treating this problem as a global emergency,” said Haynes, who has been working in the field for 27 years and leads the NIH’s Center for HIV/AIDS Vaccine Immunology.

One of the challenges of vaccine development is that HIV is an extraordinarily diverse virus, changing its character every time it replicates. An infected person may harbor hundreds of thousands or millions of different variations of the virus. So a vaccine needs to generate an immune reaction that is clever enough to recognize all of these variants.

I can assure you the HIV vaccine field is invigorated.

Vaccine researchers were encouraged in their quest by the results of a trial among 16,000 people in Thailand, reported in 2010, which showed a 31 percent reduction in infections. The vaccine was all too limited in its effectiveness, but it nonetheless pointed the way forward.

Since then, researchers have been following some of the trial participants and identified some immune “correlates” – clues on what it is about the immune response that can help predict whether a vaccinated person will be protected or not, Haynes said.

At the same time, scientists have identified several potent new neutralizing antibodies with broad ability to recognize different viral strains, Haynes said. These can be combined with so-called adjuvants, which boost the immune response, to form the basis for new clinical trials.

Haynes likened the struggle for a vaccine to the global arms race: Every time a weapon is introduced, a new, more powerful one is built. In HIV, every time an antibody attacks a virus in the body, a new “escape” virus is created, and HIV wins.

Now, he said, “We hope to create the human HIV arms race with a vaccine and a strong adjuvant so the vaccinee wins.”

Ruthann Richter is a Scope contributor and writer in the medical school’s communication office. She is attending the International AIDS Conference in Washington, D.C. and is posting periodic updates on the happenings there. You can see all of her updates in our HIV/AIDS category.

When I first heard that a group of Guatemalan clowns were staying with some of my relatives on the East Coast, my interest was piqued. A few Facebook messages later I learned that the clowns weren’t the Ronald McDonald type but instead were professional health educators – part of a non-profit organization aiming to increase awareness of HIV and other sexual-health issues among vulnerable populations. Several members (i.e. clowns) of the Asociacion Payasos Atz’anem K’oj have come to Washington D.C. to present at the International AIDS Conference, and – still intrigued – I recently spoke with project coordinator Anthony Savdie about their work.

Who first identified a need to address sexual health and human rights in vulnerable communities? And what led to the establishment of Asociacion Payasos Atz’anem K’oj in 2001?

The need to shift the focus to the rural poor was first identified in a report from the Food and Agricultural Organization and UNAIDS, called Sustainable Agriculture: Rural Development and Vulnerability to the AIDS Epidemic, which was published very quietly in 1999. It outlined a series of vulnerability criteria for communities where statistics don’t yet exist. Paul Farmer, MD, PhD, has also written about HIV, in Haiti and elsewhere, and he persuasively argues for a public-health effort that uses an analysis of poverty as the lens through which sexual health is examined. We in Guatemala – and by we, I mean the original team of Proyecto Payaso, a group that included an HIV educator, several performers and others interested in developing a project to address the issue – recognized a situation in the indigenous majority of the Western Highlands that clearly put large segments of the population at risk. Migration, poverty, and a lack of access to condoms, testing and basic information all seemed to point at the region as the next epidemiological time bomb.

The Atz’anem K’oj Collective formed in early 2001 to propose a communications project based on organic, face-to-face exposure to accurate, up-to-date and scientifically proven information formulated in a way as to be intelligible to people with little Spanish and little exposure to formal education.

What is the current state of sexual health and HIV awareness in the Guatemala? Who has the biggest need for accurate information?

The pandemic has exhibited worldwide tendencies over the last decade that have been very well documented: HIV is affecting, increasingly, women and the poor, and it is shifting disproportionately to rural areas. Indigenous women in Guatemala fall under all three categories; it is therefore logical that they should be the most vulnerable both to the spread and to the impact of HIV. Cultural mores that dictate women’s subservience and ignorance of their bodies, health and rights have conspired with centuries of structural violence and historical neglect that have kept an estimated 85 percent of indigenous women in Guatemala from basic services such as education. We know, then – with or without hard epidemiological statistics – that women are under-resourced in terms of sexual health.

If we look at reproductive health statistics, which actually do exist, we have an indication of the general state of women’s health in Guatemala. It is, as you may guess, not very good. Maternal mortality is almost the highest in the hemisphere, second only to Haiti, and the only reason, in our view, that HIV statistics among indigenous women are not through the roof is that testing and counseling services are nonexistent in areas of indigenous majority.

Your clown-educators – who, I understand, perform in big shoes and red noses – use games, workshops and theater to increase access to information and resources on HIV. Can you provide a few examples of how this is done?

A board game gathers twelve people around a 50-square circuit, and it’s a race to the end with the roll of one or two dice. If you roll a six, for instance, you land on a square where you are asked to put a condom on [an object] following the correct steps. If you roll a five you are instructed to pick from a stack of hypothetical situations and asked to determine whether you are in fact in a risky situation – whether the described behavior could end up causing a new infection, either HIV or some other STD. Another square announces that your HIV test has come back positive and asks you to discuss whom you might tell first and why, another square asks you to name three bodily fluids capable of transmitting HIV from one person to another, another tells you to roll again because you went to the health post and asked for condoms and they gave them to you. You get the drift.

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AIDS researchers today are talking about something almost unthinkable a few years ago: a cure. At the International AIDS Conference, research to eradicate the virus took center stage with a major presentation by a Spanish scientist on efforts to understand how the virus persists in the body and to find ways to flush it out and eliminate it entirely. The International AIDS Society, which has convened a group of experts to lead the effort, also unveiled a roadmap for priorities in cure research in the coming years.

The work has important implications: People on antiretroviral therapy may suffer serious side-effects, including cancer, liver disease and heart disease, that can shorten their lives, said Javier Martinez-Picado, PhD, a senior investigator at IrsiCaixa AIDS Research Institute in Barcelona. Moreover, the cost of maintaining people on the therapy could reach $22 billion by 2015, he said.

But work on the cure is proceeding cautiously, as scientists have gone down this path and been disappointed before, researchers Steven G. Deeks, MD, and Francoise Barre-Sinoussi, PhD, leaders of the effort, discuss in the latest issue of Nature Reviews Immunology.

“The barriers to curing HIV are real, and they may prove to be insurmountable,” they write.

What makes viral eradication so challenging is the fact that the virus integrates itself into the DNA of specialized immune system cells and can remain there indefinitely without detection. Scientists are just starting to develop tests to measure these latent cells not only in the blood, but in other body tissues, such as the lymph nodes or genital tract, where they may be hiding out, Martinez-Picado said.

The next few years also will see the development of animal models to better understand viral latency, as well some small clinical trials with several drugs that work through different mechanisms. The first preliminary results emerged in March of this year, when David Margolis, MD, of the University of North Carolina at Chapel Hill, reported that the cancer drug Vorinostat could flush out latent cells. In theory, antiretrovirals then could be used to mop them up.

“Certainly, this is promising,” Martinez-Picado said at today’s meeting.

One patient already stands as proof of the possibility of cure. He is the so-called Berlin Patient, an HIV-infected man who received a bone marrow transplant for leukemia from an HIV-resistant donor. Five years have passed, and today he remains entirely free of HIV.

Ruthann Richter is a Scope contributor and writer in the medical school’s communication office. She is attending the International AIDS Conference in Washington, D.C. and is posting periodic updates on the happenings there. You can see all of her updates in our HIV/AIDS category.

By all rights, he should be dead today. He was a self-destructive, angry young man who got mixed up in drugs and alcohol and took a lot of sexual risks in the free-wheeling, AIDS-ridden 1980s.

“I should have died of AIDS… I shouldn’t be here today,” British singer Sir Elton John told some 5,000 people at the International AIDS Conference today.

But he was saved by the love and compassion of complete strangers, who cared for him during his dark days of drug rehabilitation. And that’s the message he’s preaching today – that with all the best science in the world, people won’t be saved from HIV/AIDS as long as there is hatred, discrimination, stigma and lack of compassion for marginalized groups affected by the epidemic.

We need to put our arms around people who are HIV-positive and celebrate those who go to be tested.

John founded the Elton John AIDS Foundation in 1992 after he came to know Ryan White, the Indiana teenager who contracted AIDS through a blood transfusion. After White’s death in 1990, he began to take stock of his own life. He writes about his experiences in his new book, “Love is the Cure.”

In his talk at the conference, where he appeared in an uncharacteristically conservative black suit and blue shirt, he said he experienced the shame of a drug addict, and it’s the same shame that keeps many at-risk people from emerging into the mainstream to seek HIV testing and care today.

“They feel subhuman, worthless, like they don’t matter at all,” he said. “It prevents them from getting treatment.”

The AIDS epidemic has led people to be ostracized by families, for African men to be subject to stoning, for orphaned children to be abandoned in the streets, and for injection drug users to be considered lawless citizens in some parts of the world. But all this does is push people further into the shadows, causing needless suffering and further contributing to the spread of AIDS.

“We need to put our arms around people who are HIV-positive and celebrate those who go to be tested,” John said.

Compassion, he said, “doesn’t cost anything, but it’s the most precious thing in the world… When we find it, I promise you we will wake up from this 30-year nightmare into a brand new day.”

Ruthann Richter is a Scope contributor and writer in the medical school’s communication office. She is attending the International AIDS Conference in Washington, D.C. and is posting periodic updates on the happenings there. You can see all of her updates in our HIV/AIDS category.

U.S. Secretary of State Hillary Clinton brought more than 7,000 people to their feet today with her memories of the millions lost to AIDS and her vision to bring about an AIDS-free generation.

Speaking for the first time at the International AIDS Conference, Clinton laid out an ambitious domestic and global agenda. It includes:

• funding to bring 600,000 more people into treatment, in addition to the 4 million already receiving antiretroviral drugs through the U.S. President’s Plan for AIDS Relief (PEPFAR);
• providing more HIV-positive pregnant women with therapy so their unborn children remain virus-free, with a goal of reaching 1.5 million by next year and reducing transmission to zero by 2015;
• investing more in circumcision programs, which have been shown to reduce chances of viral transmission by more than 60 percent. The U.S. will contribute $40 million this year to help 500,000 South African men undergo circumcision, Clinton said.

Clinton said she remembered her first visit to the AIDS quilt on the mall in downtown Washington, D.C. with her husband, President Bill Clinton, in 1996. She recognized the names of many friends in the commemorative art work.

“When we saw how enormous the quilt was, covering acres and acres of ground, it was devastating. And it kept growing. Too many people kept dying… We are here today because we want to stop adding names,” she told the audience in somber tones. “Today, let us restore our faith so we may reach that goal of an AIDS-free generation and honor all those who have been lost.”

Though Clinton acknowledged that the U.S. has been criticized in the past for not doing enough, today it remains the largest single funder of global AIDS, committing 59 percent of the $7.6 billion spent by governments in 2011, according to a new report by UNAIDS. U.S. funding slid in 2009 and 2010 but has since returned to 2008 levels, the report indicated.

Clinton, who was recognized by UNAIDS director Michel Sidibe as “one of the most committed visionaries to change,” said U.S. strategy has shifted from emergency mode to one of building sustainable health care systems around the world.

“We have had to fundamentally change the way we – and our global partners – do business,” she said. “That has required some difficult conversations, like talk about government corruption and delivery of drugs.”

On the domestic front, the Obama administration inaugurated the first comprehensive national AIDS program in July 2010 to fight an epidemic which affects some 1.1 million Americans. Some 20 percent of those infected don’t know it, and only 62 percent are linked to care, said Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Disease. And only 28 percent are receiving therapy that is effective enough to keep the virus in check, Fauci said. So throughout the United States, and particularly in hot spots like Washington, D.C., “there still needs more resources and smarter strategies,” Clinton said.

Ruthann Richter is a Scope contributor and writer in the medical school’s communication office. She is attending the International AIDS Conference in Washington, D.C. and is posting periodic updates on the happenings there. You can see all of her updates in our HIV/AIDS category.

The International AIDS Conference opens today in Washington, D.C. My colleague, Ruthann Richter, is attending the conference and will be writing about her experiences there.

With the conference in mind, I’ve selected this image of Patrick, a young African boy, as this week’s image. Patrick’s mother, who is pictured in the background, died from AIDS-related complications in 2004. Patrick, thankfully, is not HIV-positive and is healthy. He is now in an orphanage and recently received an award for being the first in his class.

The photo comes from Ruthann’s award-winning book, Face to Face: Children of the AIDS Crisis in Africa, which she authored with Karen Ande.

Previously: International AIDS Conference: Day One and Image of the Week: Esther
Photo by Karen Ande

For the first time in 20 years, the International AIDS Conference opens today in the United States following the lifting of the travel ban in January 2010 that prevented HIV-positive people from entering the country. Because of its venue in the nation’s capitol, the conference, always a vibrant stage for AIDS activists, will feature more than the usual number of politicians – from former Presidents George W. Bush and Bill Clinton to Secretary of State Hillary Rodham Clinton and Senators John Kerry and Lindsay Graham. Some 25,000 people will crowd the Washington Convention Center for the six-day conference, which will include these highlights:

• For the first time, scientists are focusing their attention on seeking a cure for HIV. A cure would free the millions of people on antiretroviral therapy from the daily burdens and side-effects of medication, as well as reduce the enormous global cost of therapy, estimated to reach $22 billion to $24 billion by 2015. But it constitutes a huge scientific challenge, as the virus embeds itself in immune system cells and can hide out there for years, avoiding detection.
• With a theme, “Turning the Tide Together,” conference leaders see the world on the cusp of a new era in AIDS, with many tools available to control the disease, but limited resources for implementation to broad populations. In recent years, major studies have shown the value of treating people as a way to prevent transmission of the virus and have led to recent FDA approval of an antiretroviral drug that can be used as a preventive in uninfected people. Yet funding for these and other treatment strategies is becoming scarce, with the global commitment remaining flat since 2008, according to a recent report from UNAIDS.
• With global AIDS investments at risk, major policy figures, including Bill Gates, will talk about the most effective and efficient use of resources. Eric Goosby, MD, the U.S. Global AIDS Coordinator (who was targeted by activists at the last AIDS conference in 2010), will participate in the Monday discussion.
• Appearances by major public figures, including singer Elton John, who founded the Elton John AIDS Foundation in 1992. He will deliver a keynote Monday in a special session on public-private partnerships.

Ruthann Richter is a Scope contributor and writer in the medical school’s communication office. She is attending the International AIDS Conference in Washington, D.C. and is posting periodic updates on the happenings there. You can see all of her updates in our HIV/AIDS category.

As you may have heard, the U.S. Food and Drug Administration yesterday approved the drug Truvada as a preventative measure for HIV-negative individuals who are at high-risk for contracting the virus. The pill, which is already used in patients with HIV, has been shown to reduce the risk of infection.

A segment on KQED’s California Report today focused on some of the controversies surrounding Truvada’s approval, including concerns from doctors and researchers about how the drug could encourage users to forego safe sex practices. Andrew Zolopa, MD, director of the Stanford Positive Care Clinic, told reporter Joshua Johnson:

There’s no magic bullet here. It’s not just a pill by itself – it really does require careful prevention planning, safe sex education, the use of condoms… All of those things still are required as well as medical monitoring for the medication, because of course there are side effects to medications. All medications, even a medication as good as the one that’s just been approved for prevention, Truvada, do have side effects.

Previously: FDA panel recommends use of new cost-effective tool to curb AIDS epidemic, Preventing HIV with daily drug is costly but useful and Treat patients early to stop HIV spread, study finds

Symptoms of depression and dementia among HIV patients could be attributed to the viruses ability to kill off neurons in the brain, according to a small study from Georgetown University Medical Center. The research, led by Italo Mocchetti, PhD, was recently published (subscription required) in The Journal of Neuroscience.

Mocchetti found that the virus destroys neurons by attacking their source of protein growth, known as mature brain-derived neurotrophic factor (mature BDNF). PsychCentral explains:

Their scientific break came when they were able to study the blood of 130 women who were enrolled in the 17-year-old, nationwide Women’s Interagency HIV Study. In one discovery, Mocchetti and colleagues found that when there was less BDNF in the blood, patients were at risk of developing brain abnormalities.

“The link between depression and lack of mature BDNF is also known, as is the link to issues of learning and memory,” he said. “That’s why I say HIV-associated dementia resembles the aging brain.”

Loss of mature BDNF has also been suggested to be a risk factor in chronic diseases such as Parkinson’s and Huntington’s diseases, Mocchetti says.

Researchers say the findings could lead to the development of new therapeutic interventions, which may also be useful in treating patients suffering from other brain ailments that appear to develop in the same way such as the elderly.

Previously: Looking at the HIV/AIDS epidemic’s effect on black Americans and The ‘ethical odyssey’ of an HIV trial
Photo by Sander van der Wel