AIDS campaigners dismayed over UK Global Fund pledge

International development organisations in the UK have expressed dismay over the UK’s new pledge to the Global Fund to Fight AIDS, Tuberculosis and Malaria, which they say falls far short of expectations.

The Global Fund is an international funding facility that provides grants to developing country governments and organisations that are tackling AIDS, Malaria and TB. The UK, one of the Fund’s biggest donors, has provided £100 million (approx. $ 200 million) to the fund every year for the past three years. The international development secretary, Douglas Alexander has now promised £1 billion over the next eight years, which equates to around £ 125 million per year.

While the new pledge is an increase on previous donations, it does not tie-in with the promise made by the G8 in July this year to triple donations to the Global Fund by 2010. It has also come as a great disappointment to many who were hoping Gordon Brown, the UK’s new Prime Minister, would continue his previously demonstrated interest in international development issues by increasing international aid.

"It is astonishing how quickly promises become meaningless. In June the G8 promised to treble the size of the Global Fund by 2010, in order to tackle three diseases that kill 6 million people each year. Then in July, at the UN, Gordon Brown claimed moral leadership by warning the world that promises to tackle poverty and disease must be not be broken. Yet today the government has done exactly that, and sadly the effect will be felt by millions of people affected by Aids, TB and malaria across the world," said Steve Cockburn of the UK’s Stop AIDS Campaign.

The UK’s pledge is important both for financing Global Fund programmes and for encouraging others to increase their donations to the Fund. The USA for example has agreed to provide one third of total Global Fund money each year. The less money fellow donors pledge, the less the USA is therefore obliged to donate.

Greater funding for AIDS in particular is desperately needed to achieve the international target of universal access to HIV treatment, care and prevention by 2010. A new report from UNAIDS this week suggested that there is already a US$ 8.1 billion funding gap for 2007 alone. By 2010, around $ 42 billion will be required to ensure that at least 80% of people living with HIV worldwide have access to the services they need. At the current rate of increase, only around $ 17 billion is actually likely to be available.

“The lack of investment 10-20 years ago in the AIDS response, particularly in strengthening health systems and on issues contributing to the drivers of the epidemic such as violence against women and education has resulted in a more serious epidemic and the higher levels of funding needed today,” UNAIDS claims.

The report presents two scenarios for reaching universal access worldwide. The first would see universal access achieved by 2010 and would require a dramatic expansion of services in all low- and middle-income countries affected by AIDS. The second would achieve universal access in 2015 through a phased scale-up based upon individual country targets. This would allow countries to expand services at a more manageable pace and would cost less in the long-term, but more lives would ultimately be lost.

More information about the Global Fund to Fight AIDS, TB and Malaria and the Universal Access by 2010 goals are available on the AVERT website.

New report highlights strengths and weaknesses of major AIDS donors

A new report by HIV/AIDS Monitor and the Center for Global Development has for the first time provided a comparative evaluation of the three major donors of AIDS-related funding: the Global Fund for AIDS, Tuberculosis and Malaria, The World Bank and the US President’s Emergency Fund for AIDS relief.

The report, entitled “Following the funding for HIV/AIDS: a comparative analysis”, focuses specifically on the organisations’ work in Mozambique, Uganda and Zambia. Highlighting the strengths and weakness of each project, it highlights how much developing countries have come to rely on funding provided by the three agencies. In Mozambique for example, government contributions currently make up just 2% of the total sum being spent on AIDS in the country, the rest being derived from PEPFAR, and to a smaller extent, the Global Fund and World Bank.

PEPFAR is by far the largest donor of international funding for AIDS in the three countries, providing 62% of AIDS resources in Zambia, 73% in Uganda and 78% in Mozambique. The programme was praised for its ability to distribute fund quickly and directly. However, much of PEPFAR’s funding is channelled through international (often American) non-governmental organisations, meaning there is little government involvement, and no clear way of handing over responsibility to local stakeholders in the long-term.

The report welcomed the Global Fund’s transparent and flexible funding agreements arranged largely by national governments, but pointed out that a lack of capacity to absorb and process large sums of money meant the distribution and spending of funds was often very slow and involved a great deal of bureaucracy.

Finally, the World Bank, the smallest funder of the three, was praised for its work on strengthening government capacity to cope with AIDS, but as with PEPFAR, doubts were raised about its rigid donor-dictated requirements that mean money is usually allocated according the prerogative of the Bank rather than the country in question.

The paper goes on to recommend greater collaboration between the three agencies, both so funding can be allocated evenly and appropriately, and so each organisation can learn from the others’ successes and failures.

“By learning from each other to fix what is not working and by sharing what is working, PEPFAR, the Global Fund and the World Bank MAP can individually and collectively improve their performance in the fight against AIDS in Africa,” the report states.

Spending on AIDS-related programmes has increased 30-fold since 1996, and last year stood at US$ 8.9 billion. However, this is still far short of the amount that UNAIDS estimates is needed to meet the Millennium Development Goal of reversing the spread of HIV by 2015, and the goal of providing universal access to HIV treatment by 2010.

You can read more about PEPFAR, The Global Fund and other major financing initiatives for AIDS on the AVERT website.

Millions more faulty condoms recalled in South Africa

The South African Department of Health has called for the return of millions of condoms distributed as part of the government's HIV prevention efforts, after some were found to be defective.

This new development comes two months after the government recalled 20 million faulty condoms made by a company called Zalatex. An official from the South African Bureau of Standards (SABS) has been accused of accepting bribes to approve the Zalatex condoms, which failed to meet quality standards.

Now it has emerged that five batches of condoms made by Kohrs Medical Supplies have failed an air burst test. This shows the condoms were not as strong as they should have been, though it does not necessarily mean they would have burst during normal use. There is no evidence that bribes were involved in this case.

One million Kohrs condoms are already in quarantine and the government is appealing for the return of all others bearing the batch number 6809/MED. It is thought that up to four million such condoms may be in circulation. So far barely half of the 20 million Zalatex condoms have been recovered.

Experts fear the recalls could undermine public confidence in condoms and jeopardise South Africa's HIV prevention campaigns.

"It's very frustrating. Condoms are one of the few things we are getting right on prevention," said Dr Francois Venter, president of the Southern African HIV Clinicians' Society. "Heads should roll."

The government has cancelled its contracts with Zalatex and Kohrs. This leaves five companies supplying the 425 million condoms distributed each year.

In a statement to the media, South Africa's Minister of Health, Dr. Manto Tshabalala-Msimang, sought to reassure the public.

"The SABS has indicated that extensive controls and verifications have been implemented throughout the testing and certification process to ensure that all condoms supplied under the SABS mark and under the Choice brand, comply with standards set by the World Health Organisation," said the health minister.

"The two incidents involving Zalatex and Kohrs should not be allowed to impact negatively on the significant progress we have made in promoting condom use in the country."

AVERT.org has more about AIDS in South Africa.

AIDS vaccine may have worsened risk of HIV infection

Hundreds of South Africans who received an experimental AIDS vaccine have been warned that it may have increased their risk of HIV infection.

The study, which began in January, was meant to establish whether a product made by the pharmaceutical company Merck could protect people from HIV. It was stopped last month after researchers found no evidence of effectiveness.

Now it has been revealed that the infection rate was higher among people who received the vaccine than among those given a placebo. Nineteen vaccinated volunteers acquired HIV, compared to eleven in the placebo half of the study.

Every trial participant is now being told whether they received the vaccine or the placebo, and is being warned of the possible consequences.

Merck's vaccine candidate was separately trialled in 3,000 volunteers from the USA, Canada, Australia, Peru and the Caribbean. That study, which began in 2004, was halted at the same time as the South African trial. The ethics board has yet to decide whether to inform the participants - mostly gay men - if they received the vaccine or the placebo.

Experts say the vaccine itself could not have caused HIV infection, but it may have increased the risk of transmission by affecting immune responses.

"Given the complexity of the issue, we feel the best conclusions will be reached when all the data are analyzed in their entirety," said Mark Feinberg, vice president for medical affairs and policy for Merck.

More details are likely to emerge when vaccine researchers meet in Seattle early next month.

Not only is this outcome a major disappointment for researchers, but it may also affect people's willingness to take part in similar trials in the future. A trial of an HIV microbicide was stopped in January after it too found more infections in the treated group compared to those who received a placebo.

AVERT.org has more about AIDS vaccines and microbicides.

Mbeki still unconvinced of HIV/AIDS link, says biographer

A new biography of the South African President, Thabo Mbeki, has uncovered ongoing ‘dissident’ beliefs about HIV and AIDS, an article in The Guardian newspaper has revealed.

Mbeki courted much controversy in 1999 by questioning the safety and efficacy of AZT, one of the first antiretroviral drugs. He then caused a similar storm in 2000 by repeatedly casting doubt on the widely held belief that HIV is the cause of AIDS.

Mbeki officially withdrew from the debate on the cause of AIDS in 2000, though arguments continued within the government. In 2002, Pregs Govender, the chair of a parliamentary committee on the status of women resigned over the issue, and several fellow members of the government strongly criticised Mbeki's views. The President has stayed away from the debate in recent years, though the new biography by the respected author Mark Gevisser reveals that he remains unconvinced of the HIV/AIDS connection to this day, and is aggrieved that he was silenced by colleagues who believed his opinions to be damaging for the country. Though Mbeki has never expressly said that HIV does not cause AIDS, his obvious scepticism has had a deep impact on the government’s reaction to the AIDS crisis. His views are also now shared by the country’s health minister, Manto Tshabalala-Msimang.

In the book, Gevisser describes how Mbeki contacted him personally to tell him of a paper he had secretly authored six years previously and distributed anonymously among senior members of the Africa National Congress. The paper, which Mbeki took care to have personally delivered to Gevisser, compared AIDS scientists to Nazi concentration camp doctors and depicted black people who accepted the standard rhetoric on AIDS as victims of a slave mentality. The paper also describes the "HIV/Aids thesis" as entrenched in "centuries-old white racist beliefs and concepts about Africans".

Much of Mbeki’s career was spent fighting against Apartheid during the many years that South Africa was a nation divided by race. As a consequence, says Gevisser, Mbeki holds a deep suspicion of white ‘colonial’ orthodoxies, and believes AIDS to be a prime example of racist attempts to demean and repress black Africans. He also believes that much of the Western world is in league with pharmaceutical companies in their attempts to make money out of AIDS by selling potentially dangerous treatments.

Over two million people have died of AIDS in South Africa since the first cases were reported, and about nineteen percent of adults are thought to be infected with HIV. The government has in recent years made greater efforts to address the epidemic, and began to distribute antiretroviral drugs in 2003, "but that did not mean, in any way, that [Mbeki] had changed his mind," writes Mr Gevisser. "When I asked him in 2007 how he felt about having to withdraw from the Aids debate, he told me it was 'very unfortunate' that his initiative had been 'drowned'."

Mark Gevisser's biography of Thabo Mbeki goes on sale in South Africa from 7th November.

Generic antiretroviral manufacture has saved Brazil US$ 1 billion.

Brazil’s policy on AIDS drugs has saved the country around US$ 1 billion since 2001, a new study in PLOS medicine has found.

In 1996, Brazil became the first developing country to commit to universal access to antiretroviral AIDS drugs for all HIV positive Brazilians that needed them. To achieve this goal, the country significantly expanded its drug manufacturing capabilities, and today produces eight different antiretroviral drugs (ARVs) in ‘generic’ (i.e. copied) forms. For drugs that are still within their patent period and cannot be copied under intellectual property laws, Brazil has either broken the patent using a compulsory license (in the case of efavirenz) so it can import generic versions from abroad, or it has negotiated significant price reductions for the brand named versions.

The bold programme has proven controversial with major pharmaceutical companies and the US Trade Representative, as they see it as breaching the intellectual property rights of the original manufacturer. However, under World Trade Organisation guidelines, Brazil’s actions are completely legal.

The study, published by researchers at the Harvard School of Public Health in the United States, described Brazil’s efforts and the $ 1 billion saving as “remarkable”, yet they also warned that the relatively high cost of generic ARVs in Brazil, and the increasing HIV positive population may cause problems in the future. The lack of competition for generics manufactured in the country (all are produced on government orders) means that they are more expensive than generics found in other nations (such as in India). The country has an adult HIV prevalence rate of 0.5% and is currently treating around 180,000 people, with numbers growing all the time.

The study’s authors hope that their work will be of use to other developing countries facing an ever-expanding bill for antiretroviral treatment.

“The trends this study highlights provide important information about how AIDS treatment costs are likely to evolve in other developing countries as efforts are made to provide universal access to life-saving ARVs.” the researchers stated. “The specific application of the Brazilian model to other countries will depend, however, on the strength of their health systems, intellectual property regulations, epidemiological profiles, AIDS treatment guidelines, and differing capacities to produce drugs locally.”

AVERT.org has more about AIDS in Brazil and generic antiretroviral treatment.

CDC set to announce big rise in US HIV infections

The US Centers for Disease Control and Prevention (CDC) is set to announce a dramatic increase in the annual number of HIV infections occurring in the USA, an article in the Washington Blade has claimed.

Current CDC literature states that around 40,000 people become infected with HIV every year, a rate that has remained stable since 1992. However, sources at the CDC have told the Washington Blade that the actual figure may now be over 60,000.

It is unclear exactly what has caused the increase, and the CDC is officially remaining tight-lipped on the subject. Greater HIV testing in a wider range of venues, a CDC initiative introduced last year, may be one explanation. Two employees of the agency have also suggested that more accurate reporting techniques recently introduced across the US may have contributed to the rise. If this were the case, it would suggest that annual incidence may have been underreported for some years.

“My view is it’s both better data collection and increased testing as well as a higher rate of [HIV] conversion that is causing the spike in the CDC numbers,” said David Reznik, the head of an HIV dental clinic in Atlanta, Georgia, and former member of the Presidential Advisory Council on HIV/AIDS.

“However, our prevention messages aren’t reaching those at most risk,” Reznik said. “And I believe it’s time to rethink our prevention strategy.”

Government prevention efforts in the USA mainly consist of encouraging greater HIV testing, and there is currently no national scheme to encourage safer sex. If the new statistics are accurate, it is likely that many AIDS organisations will call for a reappraisal of this situation.

The CDC has admitted it is unlikely it will publish the new data, or its annual HIV/AIDS surveillance report, before World AIDS Day this year, stating that it needs more time to subject the data to peer review. Such a move has however drawn accusations of an attempted cover-up.

“The word we’re hearing now is they’re leaning against releasing such bad news on World AIDS Day,” said Jim Driscoll, a Washington adviser to the AIDS Healthcare Foundation. “There’s some talk of them releasing the new figures during the week between Christmas and New Year’s, when the fewest possible people will be paying attention.”

While a quiet launch of the figures may cause less embarrassment for the CDC, it would represent a major missed opportunity to highlight the ongoing seriousness of the AIDS epidemic in the United States.

To find out more about AIDS in the USA, please visit our HIV & AIDS in America section.

UNAIDS releases dramatically revised global HIV estimates

The joint United Nations Programme on AIDS (UNAIDS) has dramatically reduced its estimate of the number of people living with HIV around the world. According to the new statistics, there are now 33.2 million people living with HIV globally, down from the 39.5 million estimate made at the end of 2006.

Much of the reduction can be attributed to better surveillance techniques now being used in many countries, most notably India. Earlier this year, India reduced its HIV estimate by around 3 million people after numbers from a large household survey showed HIV prevalence was much lower than previous antenatal clinic and surveillance site data had suggested. This trend has been echoed in several other countries, and has led UNAIDS to adjust antenatal survey estimates downwards by an average factor of 0.8 for the 2007 report. Antenatal surveys are considered less accurate than more general population sampling, as many of the women that access antenatal clinics will be (by default) more sexually active than other members of the population, and at a higher risk of having HIV.

Not all of the reductions in the new report are attributable solely to technical changes however. Encouragingly, in countries such as Kenya, Zimbabwe and Côte d’Ivoire, HIV prevalence has dropped, a trend which country officials say is due to behaviour change and greater awareness of AIDS. In Sub-Saharan Africa as a whole, there were an estimated 1.7 million new HIV infections in 2007 – considerably fewer than in 2001, when comparatively accurate monitoring of HIV rates first began.

Deaths from AIDS have also fallen, with an estimated 2.1 million people dying in 2007, down from around 2.3 million in 2005.

“For the first time, we are seeing a decline in global AIDS deaths," said Dr. Kevin De Cock, director of the AIDS department at the World Health Organization.

He attributed this decline to better global access to antiretroviral drugs, as well as the fall in HIV prevalence now being seen in many African countries.

"These improved data present us with a clear picture of the AIDS epidemic," added UNAIDS Executive Director, Dr. Peter Piot. "Unquestionably, we are beginning to see a return on investment."

Not everyone believes that the current statistics are any more accurate than previous estimates however. The AIDS Healthcare Foundation in the USA is arguing that the uncertainty highlights fundemental problems in the world's approach to AIDS.

"These figures are rough numbers based upon extrapolations gleaned from unreliable data, since so few people are being tested," said Michael Weinstein, the AHF's president. "Let's stop guessing and make routine testing worldwide a priority."

If the numbers in the new report are accurate, it would imply that the overall numbers of people infected with HIV are still increasing - revised estimates showed there were 2.5 million new infections last year. But HIV incidence - the rate at which new infections occur - is going down, and UNAIDS now believe that it may have peaked in the late 1990s.

UNAIDS has urged for the new statistics not be taken as an excuse to become complacent, or cut funding for AIDS. Dr Dr. Paul De Lay, director of Evidence, Monitoring and Policy at the organisation said that even with the downward revisions, the US$ 40 billion per year recommended for a comprehensive response to AIDS by 2010 would only drop to US$ 38 billion.

Infectiousness Of HIV May Be Reduced By Suppressing Herpes Virus

A recent study of men co-infected with herpes simplex virus type 2 (HSV-2) and HIV revealed that drugs used to suppress HSV decrease the levels of HIV in the blood and rectal secretions, which may make patients less likely to transmit the virus. This study is published in the Journal of Infectious Diseases, now available online.

Most HIV-infected persons are also infected with HSV-2, which is the major cause of genital herpes. Prior studies demonstrated that the risk of passing HIV to a sexual partner is greater when the HIV-infected person has genital ulcers caused by HSV. Previous studies among HIV/HSV-2 co-infected persons and test-tube research have also demonstrated that HIV levels are increased during genital HSV reactivation.

In a pilot study of the effect of HSV-2 suppression on levels of HIV infectiousness, Connie Celum, MD, MPH, Richard Zuckerman, MD, MPH, and a team of researchers at the University of Washington and the research organization Impacta, in Lima, Peru performed a randomized, placebo-controlled cross-over study of daily HSV suppressive treatment in a small group of HIV/HSV-2 co-infected men who have sex with men.

Twenty men aged 22 to 41 enrolled in this trial, which took place in Peru. The men studied had no prior antiretroviral therapy and were not currently receiving antiretroviral therapy for HIV infection. Subjects were randomly assigned to the anti-HSV drug, valacyclovir 500 mg, twice daily or matching placebo for initial treatment. After eight weeks, subjects had a "washout period" in which they received twice daily placebo. Subjects then crossed over to the alternative treatment (placebo or valacyclovir) for eight weeks. Participants visited the clinic three times a week during each treatment arm. At each visit, rectal secretions were collected and weekly blood samples were obtained to determine levels of HIV.

Dr. Celum and her team of researchers found significantly reduced levels of HIV in blood by about 50 percent and rectal secretions by about 30 percent during the 8 weeks when the HIV/HSV-2 co-infected men received valacyclovir to suppress reactivation of HSV. This reduction in HIV levels could have a significant impact on transmission of HIV. Since the only intervention was daily valacyclovir to suppress HSV, this study adds weight to the other evidence that HSV-2 reactivation increases HIV replication. According to the researchers, additional "ongoing randomized trials will answer whether HSV suppression can reduce HIV transmission and address the potential for HSV suppression to delay anti-HIV therapy (antiretroviral) initiation."

First In Class Integrase Inhibitor, 'Isentress'(R) (Raltegravir), Recommended For European Licence For The Treatment Of HIV

'Isentress'(R) (raltegravir), Merck Sharp & Dohme Limited's (MSD) treatment for HIV infection, has received a positive opinion from the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Evaluation Agency (EMEA) in Europe. The CHMP opinion for a conditional marketing authorisation recommends that raltegravir is used in combination with other antiretroviral medicinal products for the treatment of human immunodeficiency virus (HIV-1) infection in treatment-experienced adult patients with evidence of HIV-1 replication despite ongoing antiretroviral therapy. A conditional marketing authorisation is granted to a medicinal product that fulfils an unmet medical need when the benefit to public health of immediate availability outweighs the risk inherent in the fact that additional data are still required. The marketing authorisation holder is likely to provide comprehensive clinical data at a later stage. The CHMP, comprised of regulators from all European Union countries, gave the positive opinion following a review of data supporting the efficacy, safety and tolerability profile of raltegravir. Following the conclusion of the CHMP's review, its opinion will be transmitted to the European Commission (EC). If the EC adopts the opinion, raltegravir will be the first integrase inhibitor approved for use in the treatment of HIV-1 infection.

The CHMP decision will apply to the 27 countries that are members of the European Union, including the United Kingdom, Germany, France, Italy and Spain. After undergoing fast-track review by the Food and Drug Administration, raltegravir was approved in the United States on 12 October 2007. We anticipate a decision from the CHMP on the approval of the product in Q1 2008.

Chris Round, Managing Director of MSD, commented, "The advent of raltegravir, used in combination with other antiretroviral medicines, represents a significant milestone in the treatment of HIV infection. Up until now, highly treatment-experienced adult HIV patients, whose infection is not well controlled by their existing antiretroviral drugs, have had very few treatment options. With this, the first integrase inhibitor, a new treatment approach for this patient population is now within our sights."

About raltegravir Raltegravir, to be used in combination with other antiretroviral medicines, offers a new therapeutic option in the management of HIV and AIDS. Up until now, there have been drugs in use that inhibit two other enzymes that play a key role in propagating HIV infection - protease and reverse transcriptase - but there have not, to date, been any approved drugs that inhibit integrase.

Raltegravir, previously referred to as MK-0518, is the first in a new class of antiretroviral agents called integrase inhibitors. Integrase is an enzyme only found in viruses. There is no corresponding enzyme in humans. Integrase is used by HIV to insert its newly made genetic material (DNA) into the host cell's DNA. Inhibiting integrase from performing this function blocks the ability of the virus to replicate and infect new cells.

Tolerability profile of raltegravir

Results from pooled safety analyses from three separate studies in treatment-experienced patients taking 400 mg of raltegravir dosed twice daily plus OBT* or placebo plus OBT showed that after 24 weeks of therapy the rates of discontinuation of therapy due to adverse experiences were 2.0 percent in patients receiving raltegravir plus OBT and 1.4 percent in patients receiving placebo plus OBT.1 In addition, drugrelated clinical adverse events of moderate to severe intensity occurring in 2 percent or more patients were diarrhoea (3.7 percent vs. 3.5 percent), nausea (2.2 percent vs. 3.2 percent) and headache (2.2 percent vs. 1.4 percent) for raltegravir plus OBT and placebo plus OBT, respectively.2

Prevalence of HIV

Prevalence of HIV in the UK has shown a marked increase since the early 1980s.3 In 2005, there were an estimated 63,500 people living with HIV in the UK.3

Risk Of HIV Transmission Increased By Unstable Housing Status

New studies show that there is a demonstrable correlation between a person's housing status and his or her likelihood of transmitting or getting HIV. The groundbreaking research from the Centers for Disease Control (CDC) and others has been reported in a special issue of the journal AIDS and Behavior¹.

According to researchers from the CDC, homelessness and unstable housing "increase the risk of HIV acquisition and transmission and adversely affect the health of people living with HIV." The findings prompted the researchers to issue a call to action that "homelessness be treated as a major public health issue confronting the United States."

The first publication of its kind, this special issue of AIDS and Behavior includes 18 peer-reviewed articles on the relationship of housing status and HIV risk and health outcomes, including a policy perspective from former HUD Secretary Henry Cisneros. Research studies reported in the issue show that:

* Homeless or unstably housed persons were two to six times more likely to "have recently used hard drugs, shared needles or exchanged sex" than similar low-income persons who were stably housed.

* Receipt of housing assistance enabled homeless persons with substance use and mental health problems to achieve stability over time and to cease or reduce both drug related and sexual risk behaviors.

* Over a 12-year period, housing status and receipt of housing assistance consistently predicted entry and retention in HIV medical care, regardless of demographics, drug use, health and mental health status, or receipt of other services.

These and other findings reported in the special issue add to the growing evidence that housing itself independently reduces risk of HIV infection and improves the health of persons living with HIV. This evidence challenges the prevailing "risky person" model for understanding the co-occurrence of homelessness, HIV/AIDS and poor health outcomes.

"The findings reported here suggest that the condition of homelessness, and not simply traits of homeless individuals, influences risk behaviors and health care utilization," says Housing and HIV/AIDS Special Editor Dr. Angela Aidala of the Columbia University Mailman School of Public Health. "This points to housing as a strategic target for intervention -- a potentially exciting new tool to end the AIDS epidemic in America."

$60 Million USAID Grant Goes To Indiana And Moi Universities' AMPATH Program To Combat AIDS In Kenya

AMPATH, a program that grew out of the partnership between Indiana University School of Medicine and the Moi (Kenya) University Teaching and Referral Hospital, has received a 5-year, $60-million grant to prevent and treat HIV/AIDS in Kenya. In addition, the IU School of Medicine will augment this with $6 million over the 5 years of the grant.

The principal investigator of the grant, Robert Einterz, M.D., is associate dean for international affairs at the IU School of Medicine and co-founder of the IU-Moi partnership and AMPATH. He will coordinate all the activities between IU School of Medicine, the Moi Teaching and Referral Hospital, Moi University School of Medicine and other U.S. partners and universities collaborating in the project.

"USAID made the grant to the AMPATH program because of its success in developing and implementing treatment and prevention programs in Kenya for the past decade," said Henrietta H. Fore, the administrator of USAID, director of foreign assistance and undersecretary for management. "Through President Bush's PEPFAR program, we are making resources available in countries with a substantial HIV/AIDS burden. These resources include support for prevention efforts, care and support, and treatment for affected patients," she said.

PEPFAR, the President's Emergency Plan for AIDS Relief, which is a 5-year, $15 billion program initiated in 2003, has treated over a million HIV-positive people in 15 focus countries in sub-Saharan Africa, Asia and the Caribbean. Sen. Richard G. Lugar (R-Ind.) is sponsoring legislation to renew PEPFAR at President Bush's requested increase of $30 billion over the next 5 years.

AMPATH currently provides care for 52,000 HIV-infected patients and has reduced the rate of infection significantly. With this agreement, the goal is to expand the program to provide care to an additional 150,000 Kenyans with HIV by 2012, of which at least 70,000 will be on antiretroviral drugs, and to interrupt the transmission of HIV through home-based counseling and testing in communities served by 19 facilities. In addition, the partnership intends to improve and expand control of tuberculosis, and assist and engage communities and families to meet the basic needs of 20,000 orphans and vulnerable children within the first 2 years of the grant.

"I am proud that our government is making such a dramatic commitment to saving the lives of people suffering from HIV/AIDS," said Dr. Einterz, M.D. "As a Hoosier, I am proud that IU has taken a leadership role in caring for our African neighbors with HIV. This grant supports our core services to treat HIV patients.

"Now, along with our Kenyan partners, we look forward to moving beyond this grant to pursue our groundbreaking mission of home-based counseling and testing, and expand beyond HIV to tackle maternal and infant mortality."

The PEPFAR target in Kenya is to have 250,000 Kenyans on antiretroviral therapy by Sept. 30, 2009. The target for infections averted in the same timeframe through the prevention of mother-to-child transmission programs and other prevention efforts is 425,000. By September 2009, 450 orphans and vulnerable children and 250 people living with AIDS will be receiving palliative care in Kenya.

The grant was announced in Nairobi on Nov. 19 during a signing ceremony in the Ministry of Health Headquarters attended by Administrator Fore; Dr. Einterz, U.S. Ambassador to Kenya Michael E. Ranneberger; AA/AFR Katherine J. Almquist; USAID/Kenya Mission Director Erna Kerst; Joe Mamlin, M.D., IU professor emeritus and co-founder of the IU-Moi Partnership; and, Moi University and USAID administrators and staff members.

Several Vaccine Trials Affected By Halt Of Merck's HIV Vaccine Trial

Several vaccine trials are being postponed or modified following the halt of Merck's experimental HIV vaccine trial, the Philadelphia Inquirer reports (Stark, Philadelphia Inquirer, 11/16). Merck in September announced that it had ended the Phase II trial, which began in late 2004 and involved HIV-negative volunteers, after the experimental vaccine failed to prevent HIV infection in participants or prove effective in delaying the progression of the virus to AIDS.

New data recently suggested that the vaccine was ineffective among some trial participants with a pre-existing immunity to a common cold virus and that the vaccine might have increased their susceptibility to HIV infection. The Merck vaccine was made from a weakened version of a common cold virus that served as a mode for providing three synthetically produced genes from HIV, known as gag, pol and nef.

After several days of discussions at an HIV Vaccine Trials Network conference last week in Seattle of Merck's trial, leaders of the trial on Monday decided to notify all of the trial's 3,000 participants whether they were given the vaccine or a placebo (Kaiser Daily HIV/AIDS Report, 11/14).

According to the Inquirer, other trials have been affected by Merck's trial because the experimental vaccines have a similar structure to Merck's vaccine. Trial participants now must be warned about the potential risks highlighted in the Merck trail if they participate in experiments that use a cold-virus carrier similar to Merck's product, Anthony Fauci, director of the National Institute of Allergy and Infectious Disease, said.

Gary Nabel, director of NIH's Vaccine Research Center, was scheduled to launch the PAVE 100 HIV vaccine trial early next year, but it recently was postponed until at least mid-2008. The PAVE vaccine uses three shots of DNA followed by a cold-virus booster shot, which has different components than the Merck vaccine. Nabel said he plans to modify the study by testing the vaccine only on people with limited exposure to colds and by increasing monitoring of patients.

Hildegund Ertl -- an immunologist at the Wistar Institute who is preparing to test an experimental HIV vaccine that uses a chimpanzee cold virus -- said the Merck trial also likely will affect her study, which is due to start in a year. "The bar will be raised," she said, adding that she hopes the chimp-based cold virus will not cause complications that the human cold virus might be causing (Philadelphia Inquirer, 11/16). Vaccines Using Some Viruses Require Further Testing, Study Says
Ertl and colleagues on Thursday in the Journal of Clinical Investigation reported that experimental HIV vaccines that typically use harmless viruses called adeno-associated viruses might damage the immune system by exhausting important cells, Reuters reports.

According to the group, AAV vaccines when tested in mice directly interfered with immune cells called CD8 T-cells, which are T-cells that a vaccine is supposed to stimulate to fight HIV. "The immune cells become exhausted," Ertl said, adding, "It is simply a defense mechanism of T-cells -- if there is too much antigen for too long a time they simply turn themselves off." The researchers said AAV vaccines should not be tested on people until more studies are conducted. Ertl said it is unclear whether her findings contributed to the developments in Merck's trial, which used an adenovirus.

Fauci said the study should be taken "with a very heavy dose of caution." He added that adenoviruses and adeno-associated viruses are very different microbes, despite the similarity of their names. "We may be dealing with apples and oranges," he said.

Pat Fast of the International AIDS Vaccine Initiative said the group has stopped testing AAV vaccines. "While we find the AAV study by Dr. Ertl and her group ... very interesting and we'll consider whether it can inform our future studies, their study was conducted in mice and there are fundamental differences between mice and humans in their respective immune responses, particularly with regard to the immune response against HIV," Fast said in a statement (Fox, Reuters, 11/15).

The study is available online (.pdf).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

AMA Recommends Routine HIV Testing While Protecting Patient Autonomy, Privacy

The American Medical Association recently updated its HIV testing policy to include guidelines supporting routine HIV testing, while continuing to advocate for the protection of patient privacy and autonomy, the AP/Google.com reports (AP/Google.com, 5/14).

"Understanding and treatment of HIV has grown substantially over the past few decades," Ardis Hoven, an AMA board member, said, adding, "new policy calls on physicians to routinely test consenting adult patients for HIV and reflects the reality that if HIV is detected early patients can lead full and productive lives" (AMA release, 11/13).

CDC in September 2006 released revised recommendations on HIV testing in the U.S. The recommendations advise that HIV tests become a routine part of medical care for residents ages 13 to 64 and that requirements for written consent and pretest counseling be dropped. According to a study published last month in PLoS One, more than 30 states have laws that hamper doctors from implementing the recommendations (Kaiser Daily HIV/AIDS Report, 10/11).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Virus Used In HIV Vaccines Weakens Immune System

A new US study has shown that some of the viruses used as carriers in clinical trials for HIV-1 vaccines weaken the immune system and may do more harm than good.

Researchers primed the immune systems of laboratory mice by exposing them to fragments of HIV carried by rAAV (recombinant adeno-associated virus (rAAV) vector), a type that has been used recently in human trials. This resulted in the anticipated creation of special T cells against HIV, but they didn't work properly. They couldn't fight against infection, they didn't release enough cytokines to activate an appropriate immune response, and they didn't reproduce when exposed to HIV in a booster.

The study is the work of Dr Hildegund C.J. Ertl, director of the Wistar Institute Vaccine Center, an independent nonprofit biomedical research institute based in Philadelphia, Pennsylvania, and colleagues, and is published in the November 16th online issue of the Journal of Clinical Investigation.

Leading efforts in human trials to develop an HIV vaccine have depended on the use of viruses to carry scraps of HIV virus as a way to get the patient's immune system to make antibodies against HIV.

However, more recently, evidence has been coming forward that some of these viral "vectors" may weaken the immune system and should not be used.

This study from Ertl and colleagues gives further evidence of this, and suggests that some viral vectors could do more harm than good.

Ertl and colleagues found that while the rAAV based vaccine managed to stimulate the immune system to produce T cells specifically against HIV, as intended, those same T cells also undermined the immune system in various ways.

"Put simply", said Ertl, these results "mean that AAV vaccines against HIV may potentially cause harm and that, without additional pre-clinical studies, they should not be used in humans".

Using laboratory mice, Ertl and colleagues primed the immune system against HIV with an experimental rAAV based vaccine. Then, as would be done in a typical vaccine regimen, they followed this with a booster immunization using a vaccine based on another viral vector, adenovirus (Ad). They also carried out some booster immunizations using other viral vectors.

When they looked at the resulting immune response using follow up assays, they found that in all booster immunization cases, the HIV specific T cells induced by the rAAV vector were ineffective at preventing infection, regardless of time between prime and booster. The T cells protected poorly against HIV, they failed to secrete sufficient levels of cytokines, chemicals that stimulate the immume response, and they did not replicate sufficiently in response to the booster.

The results indicate a condition known as "T cell exhaustion", something that has been observed before with HIV, hepatitis B and hepatitis C, and some cancers like melanomas, said the researchers.

The researchers concluded that:

"Our data suggest that rAAV vectors induce functionally impaired T cells and could dampen the immune response to a natural infection."

Ertl questioned the rationale for injecting people with "a vaccine that's going to have a detrimental effect".

"AAV vaccines against HIV may do more harm than good by robbing people of their natural immune response to HIV," she warned.

Mozambique To Revise National HIV/AIDS Prevention Strategy, Health Minister Says

The Mozambican government has decided to revise its national HIV/AIDS prevention strategy after finding that the current efforts have not been effective in controlling the disease, Health Minister Ivo Garrido, recently said, AIM/AllAfrica.com reports. Garrido, who also serves as the spokesperson for the Steering Council of the country's National AIDS Council, said a meeting of the council held on Monday highlighted 10 areas that should guide the revision.

He said that the AIDS council will seek to increase coordination between HIV/AIDS advocacy groups in the country; develop a mechanism for gauging the effectiveness of HIV prevention strategies; and improve HIV counseling and testing programs. The review also will address the definition of "high-risk groups," Garrido said. He said that he believes "almost everybody" is at risk but added that a task group was established to investigate this issue.

Garrido said the Steering Council hopes to have "proposals on coordination" by early next year. The country in 2004 had an estimated HIV prevalence of 16.2% among adults ages 15 to 49 (AIM/AllAfrica.com, 11/14).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Opinion Piece Examines HIV/AIDS Policy Views Of Giuliani Adviser

A recent opinion piece by Sally Pipes -- president and CEO of the Pacific Research Institute, a think tank that receives some funding from drug companies -- about intellectual property rights and compulsory licenses for patented antiretroviral drugs is "frightening," Andrew Green, a publishing fellow, writes in the American Prospect. If Pipes were "just running a think tank with pharmaceutical funding, it could be read as a shill piece and dismissed. But there's more to Pipes' biography: She is also a health care adviser to Rudy Giuliani," the former New York City mayor who is running for the Republican presidential nomination, Green adds (Green, American Prospect, 11/15).

In her opinion piece, Pipes says it was a "staggering display of cluelessness" for Rep. Tom Allen (D-Maine) and Sen. Sherrod Brown (D-Ohio) to sponsor a resolution that praises the Thai government for its decision to issue compulsory licenses to make generic versions of patented antiretroviral drugs. She adds that Thailand's actions "threaten to upset the economic incentives that allow Western firms to produce novel cures," saying, "Without patent protections, the drug industry as we know it would collapse, and development of new drugs would be significantly curtailed" (Kaiser Daily HIV/AIDS Report, 10/18).

Pipes opinion piece "can be read both as a signal that her role is expanding and as a preview of the HIV/AIDS policy she is encouraging Giuliani to adopt, specifically one without regard for the immediate need for as many cheap generic antiretrovirals as possible," Green writes. According to Green, while this is "cause for concern," the "real crisis" is that "Giuliani might actually be receptive to her arguments."

Giuliani has "expressed an interest in continuing and possibly expanding the President's Emergency Plan for AIDS Relief," but it is "apparent" he has "thought little about what that actually means," Green says. In addition, Giuliani has not described his HIV prevention strategy or whether he would expand treatment options, according to Green. "His lack of investment or concern about the issue leaves him vulnerable to insiders like Pipes, whose business-first agendas are prepackaged," Green writes. He adds that it is "not outlandish to think that [Giuliani] might make AIDS relief contingent on buying brand-name antiretrovirals" or "levy trade restrictions and financial penalties on countries, like Thailand, that determine the best way to immediately reach the most HIV/AIDS patients is to produce their own antiretrovirals."

Green suggests that all presidential candidates "study the AIDS policy Democrat John Edwards has introduced," adding that the "first move Giuliani should make, though, is to send Pipes back to the sideline and hire some advisers whose values aren't predicated on profit margins" (American Prospect, 11/15).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

New Guide on 'Unseen' Disabilities for Small Businesses

To help small businesses avoid unintentionally discriminating against people living with long-term conditions, such as HIV and cancer, the National AIDS Trust has produced 'You can't always tell- a guide to 'unseen' disabilities for small businesses'. The free guide provides clear, practical advice to help small business owners ensure that they are providing a fair and equal working environment for employees who may be living with one of these conditions and that they are not breaking the law.

more...

No Increase in HIV Prevention Spend Despite Massive Increase in Need

The results of a survey by the National AIDS Trust suggest that investment in HIV prevention in England has stagnated, and probably decreased, over the last ten years, despite the fact that the potential for HIV transmission in the UK is greater than it has ever previously been.


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New Issue of Impact Examines HIV and the Law

The National AIDS Trust has launched the latest issue of Impact, its policy bulletin which stimulates debate on key HIV policy topics. This issue focuses on HIV and the law and aims to give an overview of both the current legal developments that can affect the lives of people living with HIV and the work that the National AIDS Trust and other organisations are doing to ensure that the law protects, rather than infringes, the rights of people living with HIV.

more...

Slide Show

Battle Over the AIDS Memorial Quilt

The creator of the AIDS Memorial Quilt is locked in a legal tug of war with the quilt�s caretaker.

Video

Tracking the Spread of HIV

A U.N. report indicates that the number of people infected with H.I.V. may have stabilized globally since the 1990s, but the disease is still proliferating in several individual countries. (Produced by Emily B. Hager)

Albany: H.I.V. Tests for Rape Suspects

Rape suspects can be forced to undergo H.I.V. testing under a law signed yesterday by Gov. Eliot Spitzer. The measure gives rape victims the option of forcing an indicted suspect to be tested under a court order, with the results provided to the victim and the suspect. Supporters say it will let victims know quickly if they need treatment. Previously, victims could request and obtain such information only after conviction.

Washing After Sex May Raise H.I.V. Risk

A study in Uganda has come up with a surprising finding about sex and H.I.V. Washing the penis minutes after sex increased the risk of acquiring H.I.V. in uncircumcised men.

The sooner the washing, the greater the risk of becoming infected, the study found. Delaying washing for at least 10 minutes after sex significantly lowered the risk of H.I.V. infection, Dr. Fredrick E. Makumbi reported on July 25 at an International AIDS Society Conference in Sydney, Australia.

The researchers do not have a precise explanation for the findings, which challenge common wisdom and the teaching of many infectious disease experts who urge penile cleansing as part of good genital hygiene. Health experts have suggested that washing the penis after sex could prevent potentially infectious vaginal secretions from entering the body through the uncircumcised penis.

Washing the penis after sex is common in Africa. To determine whether washing could be recommended as an alternative to male circumcision, Dr. Makumbi’s team from the Makerere University Institute of Public Health studied 2,552 uncircumcised men in the Rakai district of Uganda.

The men, ages 15 to 49, were uncircumcised and not H.I.V. infected when they enrolled. Eighty-three percent said they washed with all sex partners.

The researchers asked about when and how the men washed after intercourse at enrollment and 6, 12 and 24 months later, including whether they washed with or without cloths.

Because of a slip-up, the researchers did not ask details of how the cleansing was done or directly about using soap, said Dr. Ronald H. Gray, a co-author from the Johns Hopkins Bloomberg School of Public Health. Some soaps used in Africa are more irritating than those used elsewhere.

Men who washed within three minutes had a 2.3 percent risk of H.I.V. infection compared with 0.4 percent among those who delayed washing for 10 or more minutes. The National Institute of Allergy and Infectious Diseases paid for the study.

The washing analysis was a secondary part of a study undertaken to determine the effectiveness of male circumcision against H.I.V. infection. Earlier reports had shown that circumcision was protective.

One message from the study, Dr. Gray said, “is that there ought to be a little time left for postcoital cuddling before you go and wash.”

“Don’t just finish and jump out of bed,” he said.

Dr. Makumbi and other AIDS experts said they did not know why the washing practice increased vulnerability to H.I.V. infection, but offered various explanations. One is that the acidity of vaginal secretions may impair the ability of the AIDS virus to survive on the penis. Delayed cleansing — and longer exposure to the vaginal secretions — may then reduce viral infectivity.

Another is that use of water, which has a neutral pH, may encourage viral survival and possible infectivity.

H.I.V. apparently needs to be in a fluid to cross the mucosa to infect cells, Dr. Gray said. If the H.I.V.-contaminated fluid dries, its infectivity may decrease. Adding water could resuspend H.I.V. to make it more infectious.

The study findings are counterintuitive, said Dr. Merle A. Sande, an infectious diseases expert at the University of Washington in Seattle, and “show why you have to do the studies, because until you do them, you just don’t know.”

Dr. Sande, who was not involved in the study, said, “There is still so much we don’t understand about the complex factors that influence H.I.V. transmission in the genital tract, but this important study will help.”

He also is president of the Academic Alliance Foundation, a group that trains health workers to treat AIDS and other infectious diseases in Uganda.

Video: The World Hasn't Moved On

AIDS was first recognized 25 years ago. Nicholas D. Kristof travels to the country hardest hit by the virus today.

AIDS Care in Africa

Sharon LaFraniere says cheaper drugs offer hope for children, but medical staff is scant.

Reference Material on AIDS/H.I.V.

HEALTH DICTIONARY:

AIDS (aydz)

Acronym for acquired immune deficiency syndrome, a fatal disease caused by the human immunodeficiency virus, or HIV. Believed to have originated in Africa, AIDS has become an epidemic, infecting tens of millions of people worldwide. The virus, which is transmitted from one individual to another through the exchange of body fluids (such as blood or semen), attacks white blood cells, thereby causing the body to lose its capacity to ward off infection. As a result, many AIDS patients die of opportunistic infections that strike their debilitated bodies. AIDS first appeared in the United States in 1981, primarily among homosexuals and intravenous drug users who shared needles, but throughout the world, it is also transmitted by heterosexual contact. Today, scientists are hopeful that AIDS can be managed by new drugs, such as protease inhibitors, and need not be fatal. (See AZT.)

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ALSO SEE: NYT Guide to Essential Knowledge, Dictionary, Columbia Encyclopedia, Essay

ABOUT HIV/AIDS

What is HIV?

HIV (Human Immunodeficiency Virus) is a virus that causes AIDS (Acquired Immunodeficiency Syndrome), a health condition in which a person is affected by a series of diseases because of poor immunity. HIV by itself is not an illness and does not instantly lead to AIDS. An HIV infected person can lead a healthy life for several years before s/he develops AIDS.

What is AIDS?

As the name, Acquired Immunodeficiency Syndrome indicates, AIDS is a health condition that results from the deficiency in the body's immunity following HIV infection. HIV attacks the human body by breaking down its immune system that is meant to fight diseases. Over a period of time, the immune system weakens and the body loses its natural ability to fight diseases. At this stage, various diseases affect the infected person.

Human Immunodeficiency Virus

TRANSMISSION

Unprotected sex:

If a person engages in sexual intercourse with an infected person without using a condom, s/he can get infected. The sexual act can be both vaginal and anal.

Sharing of needles:

If a person shares the needle or syringe used by/on an infected person, either for injecting drugs or drawing blood or for any other purpose involving piercing, s/he can get infected. Instruments used for piercing and tattooing also carry a small risk of infection.

Unsafe blood:

A person can get the infection, if he/she is given transfusion of infected blood.

Improperly sterilised hospital tools:

If surgical devices like syringes and scalpels, or even certain instruments, used on an infected person, are used on another person without proper sterilization, they can transmit the infection.

Parent to Child:

An HIV positive mother can transmit the virus to child during pregnancy or birth. Breast milk can also act as a transmission-medium. Theoretically oral sex without condom (on men) or barriers like dental dam, vaginal dams or plastic wrap (on women) can also transmit the infection.

DIAGNOSIS How is HIV diagnosed?

In the early stages of infection, HIV often causes no symptoms and the infection can be diagnosed only by testing a person's blood. Two tests are available to diagnose HIV infection - one that looks for the presence of antibodies produced by the body in response to HIV and the other that looks for the virus itself. Antibodies are proteins produced by the body whenever a disease threatens it. When the body is infected with HIV, it produces antibodies specific to HIV. The first test, called ELISA (Enzyme Linked Immunosorbent Assay), looks for such antibodies in blood.

If antibodies are present, the test gives a positive result. A positive test has to be confirmed by another test called Western Blot or Immunoflouroscent Assay (IFA). All positive tests by ELISA need not be accurate and hence Western Blot and repeated tests are necessary to confirm a person's HIV status. A person infected with HIV is termed HIV- positive or seropositive.

As ELISA requires specialized equipment, blood samples need to be sent to a laboratory and the result will be available only after several days or weeks. To cut short this waiting period, RAPID TESTS , that give results in 5 to 30 minutes, are increasingly being used the world over. The accuracy of rapid tests is stated to be as good as that of ELISA. Though rapid tests are more expensive, researchers have found them to be more cost effective in terms of the number of people covered and the time the tests take.

The HIV- antibodies generally do not reach detectable levels in the blood till about three months after infection. This period, from the time of infection till the blood is tested positive for antibodies, is called the Window Period . Some times, the antibodies might take even six months to show up. Even if the tests are negative, during the Window Period, the amount of virus is very high in an infected person. Hence, if a person is newly infected, the risk of transmission is higher.

If a person is highly likely to be infected with HIV and yet both the tests are negative, a doctor may suggest a repetition of the tests after three months or six months when the antibodies are more likely to have developed.

The second test is called PCR (Polymerase Chain Reaction), which looks for HIV itself in the blood. This test, which recognizes the presence of the virus' genetic material in the blood, can detect the virus within a few days of infection.

There are also tests like Radio Immuno Precipitation Assay (RIPA) , a confirmatory blood test that may be used when antibody levels are difficult to detect or when Western Blot test results are uncertain. Other available tests are Rapid Latex Agglutination Assay , a simplified, inexpensive blood test that may prove useful in medically disadvantaged areas where there is a high prevalence of HIV infection, and p24 Antigen Capture Assay . Click here for Services.

Are there any steps to be followed before and after the blood tests?

The process of getting tested for HIV can generate a variety of intense emotional reactions such as fear, anger and denial. Therefore, psychological counselling is essential to prepare individuals undergoing testing for the possible consequences. This is called Pre-Test Counseling and is unavoidable for anybody preparing to take a test.

If the test result is positive, it should not be disclosed without another round of counseling. This Post-Test Counseling is more crucial because of the enormous stress and the multitude of emotions that the infected person could undergo on learning his/her HIV status. A positive test has been linked to increased suicide ideas and attempts and emotional trauma, both at the time of knowing the positive result and also at the emergence of AIDS-defining symptoms.

As there is still considerable stigma and discrimination attached to HIV/AIDS, the decision whether to test or not itself should be preceded by considerable introspection and assessment of the possible outcome. The person to take test should be aware of the emotional trauma and the possible consequences a positive test could bring about. For these reasonse, pre-test counseling is very crucial. With the help of the counselor, the person taking the test should assess his/her personal setting and prepare himself/herself for the probable consequences.

On the other hand, one should also be aware of the positive advantages of learning one's HIV status. If the test turns out to be positive, one can have early access to treatment, take care of one's health better and plan the future. Early realization of the health condition can be very useful in a large number of cases. The counselor could help the infected individual win back his/her confidence and learn how to live a healthy and responsible life. The individuals should also be prepared how to deal with their relatives, friends, colleagues, classmates etc. If the test is negative, the person should be advised preventive methods. Click here to consult an expert.

SYMPTOMS What are the early symptoms of HIV infection?
Many people do not develop any symptoms when they first become infected with HIV. Some people, however, get a flu-like illness within three to six weeks after exposure to the virus. This illness, called Acute HIV Syndrome, may include fever, headache, tiredness, nausea, diarrhoea and enlarged lymph nodes (organs of the immune system that can be felt in the neck, armpits and groin). These symptoms usually disappear within a week to a month and are often mistaken for another viral infection.
During this period, the quantity of the virus in the body will be high and it spreads to different parts, particularly the lymphoid tissue. At this stage, the infected person is more likely to pass on the infection to others. The viral quantity then drops as the body's immune system launches an orchestrated fight.
More persistent or severe symptoms may not surface for several years, even a decade or more, after HIV first enters the body in adults, or within two years in children born with the virus. This period of "asymptomatic" infection varies from individual to individual. Some people may begin to have symptoms as soon as a few months, while others may be symptom-free for more than 10 years. However, during the "asymptomatic" period, the virus will be actively multiplying, infecting, and killing cells of the immune system.
Click here to consult an expert.
What Happens Inside the Body?
Once HIV enters the human body, it attaches itself to a White Blood Cell (WBC) called CD4. Also, called T4 cells, they are the main disease fighters of the body. Whenever there is an infection, CD4 cells lead the infection-fighting army of the body to protect it from falling sick. Damage of these cells, hence can affect a person's disease-fighting capability and general health.
After making a foothold on the CD4 cell, the virus injects its RNA into the cell. The RNA then gets attached to the DNA of the host cell and thus becomes part of the cell's genetic material. It is a virtual takeover of the cell. Using the cell's division mechanism, the virus now replicates and churns out hundreds of thousands of its own copies. These cells then enter the blood stream, get attached to other CD4 cells and continue replicating. As a result, the number of the virus in the blood rises and that of the CD4 cells declines.
Because of this process, immediately after infection, the viral load of an infected individual will be very high and the number of CD4, low. But, after a while, the body's immune system responds vigorously by producing more and more CD4 cells to fight the virus. Much of the virus gets removed from the blood. To fight the fast-replicating virus, as many as a billion CD4 cells are produced every day, but the virus too increases on a similar scale. The battle between the virus and the CD4 cells continues even as the infected person remains symptom-free.
But after a few years, which can last up to a decade or even more, when the number of the virus in the body rises to very high levels, the body's immune mechanism finds it difficult to carry on with the battle. The balance shifts in favour of the virus and the person becomes more susceptible to various infections. These infections are called Opportunistic Infections because they swarm the body using the opportunity of its low immunity. At this stage, the number of CD4 cells per millilitre of blood (called CD4 Count), which ranges between 500 to 1,500 in a healthy individual, falls below 200. The Viral Load, the quantity of the virus in the blood, will be very high at this stage.
Opportunistic infections are caused by bacteria, virus, fungi and parasites. Some of the common opportunistic infections that affect HIV positive persons are: Mycobacterium avium complex (MAC), Tuberculosis (TB), Salmonellosis, Bacillary Angiomatosis (all caused by bacteria); Cytomegalovirus (CMV), Viral hepatitis, Herpes, Human papillomavirus (HPV), Progressive multifocal leukoencephalopathy (PML) (caused by virus); Candidiasis, Cryptococcal meningitis (caused by fungus) and Pneumocystis Carinii pneumonia (PCP). Toxoplasmosis. Cryptosporidiosis (caused by parasites). HIV positive persons are also prone to cancers like Kaposi's sarcoma and lymphoma.
The Center for Disease Control (CDC), Atlanta has listed a series of diseases as AIDS-defining. When these diseases appear, it is a sign that the infected individual has entered the later stage of HIV infection and has started developing AIDS. The progression of HIV positive persons into the AIDS stage is highly individual. Some people can reach the AIDS stage in about five years, while some remain disease free for more than a decade. Measurement of the viral load and the CD4 count helps a doctor in assessing an infected person's health condition. Click here to consult an expert.
What are the later symptoms of HIV/AIDS?
Lack of energy Weight loss Frequent fevers and sweats A thick, whitish coating of the tongue or mouth (thrush) that is caused by a yeast infection and sometimes accompanied by a sore throat Severe or recurring vaginal yeast infections Chronic pelvic inflammatory disease or severe and frequent infections like herpes zoster Periods of extreme and unexplained fatigue that may be combined with headaches, lightheadedness, and/or dizziness Rapid loss of more than 10 pounds of weight that is not due to increased physical exercise or dieting Bruising more easily than normal Long-lasting bouts of diarrhoea Swelling or hardening of glands located in the throat, armpit, or groin Periods of continued, deep, dry coughing Increasing shortness of breath The appearance of discoloured or purplish growths on the skin or inside the mouth Unexplained bleeding from growths on the skin, from mucous membranes, or from any opening in the body Recurring or unusual skin rashes Severe numbness or pain in the hands or feet, the loss of muscle control and reflex, paralysis or loss of muscular strength An altered state of consciousness, personality change, or mental deterioration Children may grow slowly or fall sick frequently. HIV positive persons are also found to be more vulnerable to some cancers.

TREATMENT Is there treatment against HIV and AIDS?

Till today, there is no conclusive treatment to eliminate HIV from the body; however, timely treatment of opportunistic infections can keep one healthy for many years. The commonly available treatment for AIDS is the treatment against opportunistic infections. Normally standard treatment regimens, used against such infections in non-HIV patients, also work well with the HIV-positive persons. If properly treated, almost all the opportunistic infections can be contained.

However, during the last decade, researchers have developed powerful drugs that check the replication of the virus at various levels. Called Antiretroviral drugs, they are available in three classes and under various brands. Taken in combinations (called cocktail or combination therapy) under specialised medical advice, these drugs drastically reduce the viral load in blood. However, they do not permanently cure one of HIV. This line of treatment, called HAART (Highly Active Antiretroviral Therapy) has resulted in a huge reduction or AIDS-related deaths. Though many positive persons and caregivers have welcomed these drugs, others have experienced serious side effects. They are also very expensive and are out of reach for a majority of the infected people. But of late, the prices have been steeply falling.

The three classes of drugs are:

Nucleoside analogue Reverse Transcriptase Inhibitors (NRTIs). NRTIs were the first antiretroviral drugs to be developed. They inhibit the replication of HIV in the early stage by inhibiting an enzyme (which is necessary for viral replication) called Reverse Transcriptase. The drugs include Zidovudine (Retrovir, AZT), Lamivudine (Epivir, 3TC), Didanosine (Videx, ddI), Zalcitabine (Hivid, ddC), Stavudine (Zerit, d4T) and Abacavir (Ziagen). The major reported side effect of Zidovudine is bone marrow suppression, which causes a decrease in the number of red and white blood cells. The drugs ddI, ddC and d4T can damage peripheral nerves (peripheral neuropathy), leading to tingling and burning in the hands and feet. Treatment with ddI can also cause pancreatitis, and ddC may cause mouth ulcers. Approximately 5 percent of people treated with Abacavir experience hypersensitivity reactions such as a rash along with fever, fatigue, nausea, vomiting, diarrhea and abdominal pain. Hypersensitivity reactions can also occur without a rash. In either case, symptoms usually appear within the first 6 weeks of treatment and generally disappear when the drug is discontinued. If a person had a hypersensitivity reaction to Abacavir, he/she should avoid taking the drug again. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs). These drugs bind directly to the enzyme, Reverse Transcriptase. There are three NNRTIs currently approved for clinical use: Nevirapine (Viramune), Delavirdine (Rescriptor) and Efavirenz (Sustiva). A major side effect of all NNRTIS is a rash. In addition, people taking Efavirenz may have side effects such as abnormal dreams, sleeplessness, dizziness and difficulty concentrating. Protease inhibitors (PIs). PIs interrupt HIV replication at a later stage in its life cycle by interfering with an enzyme known as HIV protease. This causes HIV particles in the body to become structurally disorganized and noninfectious. Among these drugs are Saquinavir (Fortovase), Ritonavir (Norvir), Indinavir (Crixivan), Nelfinavir (Viracept), Amprenavir (Agenerase) and Lopinavir (Kaletra).

The most common side effects of PIs include nausea, diarrhoea and other digestive tract problems. They can also cause a significant number of side effects when they interact with certain other medications. That is because all PIs, to one degree or another, affect an enzyme system in the liver that is responsible for metabolising a large number of drugs. Newer side effects have also appeared with the continuing and widespread use of Protease Inhibitors. These include elevated triglyceride levels and problems with sugar metabolism that may sometimes progress to diabetes.

There may also be abnormalities in the way fat is metabolised and deposited in the body. Some people lose much of their total body fat while others gain excess fat on the back between their shoulders (buffalo hump) or in the stomach (protease paunch). Right now, no one knows exactly why these abnormalities occur. In fact, it is not even certain whether these problems are a direct result of treatment with protease inhibitors or due to some other cause that has yet to be identified. Similar metabolic abnormalities have occurred in people on antiretroviral therapy that does not include PIs. Although these body changes can be distressing, the possibility they may occur should not stop one from obtaining treatment for HIV/AIDS.

In simple combination therapy, some physicians prescribe a combination of RTIs. But in HAART, which in fact has made a dramatic change in AIDS treatment, a combination of RTIs and PIs is prescribed.

People respond differently to treatment and maintaining the drug schedule is extremely important. Indiscriminate treatment results in drug resistance and resurgence of the viral load. Therefore it should be taken only under expert medical advice. Click here to consult an expert.

What about vaccines?

More than a dozen HIV vaccines are currently being tested. As of now, there is no vaccine to prevent HIV infection.

What is Parent to Child Transmission?

Babies born to mothers infected with HIV may or may not be infected with the virus, but all carry their mothers' antibodies to HIV for several months after birth. If these babies lack symptoms, a definitive diagnosis of HIV infection using standard antibody tests cannot be made until after 15 months of age. By then, the babies are unlikely to still carry their mothers' antibodies and will have produced their own, if they are infected. New technologies to detect HIV itself are being used to more accurately determine HIV infection in infants between ages 3 months and 15 months. A number of blood tests are being evaluated to determine if they can diagnose HIV infection in babies younger than 3 months.