People living with HIV are invited to participate in an online survey on HIV and employment in Canada. The purpose of this survey is to learn more about the education, training, employment and health needs of people living with HIV. Our ultimate goal is a national network that will provide employment support, information and advocacy opportunities for people living with HIV whether in or out of the workforce. Your responses to the survey will inform us on the employment-related issues that matter to you most.

The survey is available electronically and will take approximately 25 minutes to complete. You will be able to save survey responses and then submit the final version at a later date. If you would like to request a hardcopy of the survey please send your contact information to the address below.

You do not have to give personal information and we do not plan to publish personal information. If this plan changes, we will only do so with your agreement. You have the right to opt out of any question(s) at any point throughout the survey. You may choose to provide us with contact information if you would like to be kept updated on the progress of this project.

The link to the survey is provided below. The survey will be open for responses through Friday, March 13. This opportunity is unique to people with HIV. We look forward to your response to the survey.

http://www.surveymonkey.com/s.aspx?sm=BxPMtNFSCtrk5n1CZTiWPQ_3d_3d

March 18, 2009

Like other Metro Vancouver communities, East Vancouver has been recently caught in the horrific and terrifying gun violence, resulting from gangs involved in organized crime and drugs.

I have heard from a number of constituents who are horrified at what's taking place and have a sense of dread at the level of violence, randomness, and the impact on innocent people.

I share that horror too. No one should have to live in fear in their home and community.

Even the provincial attorney general and solicitor general have noted that "of the over 200 incidents of reported shots fired in the Vancouver region in 2008, the vast majority are a direct result of organized crime's drug trade".

Federal New Democrats in Ottawa have called for:



I am also very mindful that while we need immediate action to prevent gun violence and shootings on our streets, we cannot ignore the big question of our drug laws and prohibition and the impact it has on all of us.

It’s time to have an honest debate about prohibition and recognize that things have gotten worse not better.

The so-called war on drugs has cost billions of dollars and has incarcerated millions of people both in Canada and the U.S., and has fuelled organized crime.

Since being elected in 1997, I have been a strong advocate for changing Canada's drug laws. I have seen all too often the impacts of an enforcement regime that targets drug users, instead of recognizing the need for a public health approach.

I have always supported INSITE and other harm reduction measures, as well as accessible treatment, as a more intelligent approach to drug use.

It's time to look at new polices and a system based on regulation and control, not outright prohibition, which is no deterrence at all.

We need to recognize that drug use, both what is deemed legal and illegal, has always existed, and that the best policy is to provide realistic and honest education about substances that can be harmful, and provide help where needed for addictions.

It’s time to embark on a common sense approach and accept the overwhelming evidence that the war on drugs has caused more death, pain, harm and crime than we can bear, and that it’s time to stop it.

I know that's not going to happen overnight--but let's at least have the courage to see what's failed and what alternatives there are.

We can begin with marijuana and ensure there is real information and education, especially for young people--and ensure there are clear rules that spell out what is allowed for adult use.

Or we can continue on this tragic course of playing on people's fear and trying to convince people that tougher and tougher laws will make it all go away.

It’s not an easy debate, but I believe we have to have it and recognize what is happening here.

By Libby Davies, http://www.straight.com

March 25, 2009

OTTAWA — Canadians who have permission from the federal government to smoke marijuana for medicinal purposes are now facing impending restrictions about where they can light up.

Health Minister Leona Aglukkaq said Wednesday in the House of Commons that the government is concerned about the issue of smoking medical marijuana in public.

"That's why I have instructed my officials to examine this issue and develop options," said the health minister.

The federal government has been under pressure to clarify the rules around medical marijuana use in public. One recent request for clarification came from a bar owner in Burlington, Ont., who faced allegations of discrimination when he asked a medical marijuana user not to smoke outside his business.

The existing Marijuana Medical Access Regulations, which came into force in 2001, do not stipulate where patients can use their marijuana. While users must abide by any federal or provincial legislation and local bylaws that restrict smoking cigarettes in public places, there are no other specific prohibitions on medical pot use in public.

The government says the issue has been on its radar for some time and that it is responding to public concern in developing the new rules. It has not set a deadline for the new regulations to be in place but the department doesn't anticipate the process being too lengthy.

Health Canada officials will develop proposed regulations and present them to the health minister, who will make the final decision on the regulations.

A member of the British Columbia Compassion Club Society, a health centre that provides access to medicinal cannabis, says the organization understands the need for clear rules but hopes they are no more strict than the ones imposed on cigarette smokers.

Jayce Sale said however, that they are concerned about the impact of heavier regulations.

"It gets into a slippery slope because medical marijuana users have that right to use it and so by creating more barriers around where they can do it is a concern because it's limiting options for them," she said.

Steve Kubby, now a California resident who was a licensed medical marijuana user when he lived in Sechelt, B.C., said he is also concerned about the Canadian government's decision to take a tougher stand on medical marijuana use.

"We don't have those kinds of requirements for other people when they use their medicines," said the 62-year-old who uses cannabis daily to ease the effects of his rare form of cancer.

"It is just so difficult to understand how someone that is struggling with cancer as I am . . . my society would want to send police with guns to terrorize me and my family, tell me where I can and cannot smoke, to arrest me if I happen to be using cannabis in the wrong place or at the wrong time."

In 2004, Kubby was hiking in a park and confronted by an off-duty RCMP officer who took his joint, threw it on the ground, and told him he had no right to smoke it there even when Kubby explained he was a registered patient under the government's medical marijuana program.

He sought clarification from Health Canada who told Kubby in a letter soon after the incident that, "While Health Canada advises authorized persons not to consume marijuana in public, there are no legislated restrictions on such action." The RCMP later apologized to him.

He said people that are using marijuana for medical reasons already have enough to worry about without having to abide by rules about where to use it.

"Patients have such a struggle just to get through each day that all these layers of regulations and laws hurt people, they don't protect people, they hurt people," he said.

About 2,800 people are authorized to possess marijuana under the federal government program.

By Meagan Fitzpatrick, http://www.canada.com

March 21, 2009

When I first applied six years ago to work overseas with Médecins Sans Frontières (Doctors Without Borders), I wrote on my application that my goal was to help the world become a better place. I didn't really know what that meant or how I would do that, but it sounded like a good answer at the time.

I hadn't even arrived at my first project location before I started seeing the dark side of my chosen line of work. A month before I left on my first mission in 2002, MSF worker Arjan Erkel was kidnapped in Dagestan, a troubled Russian republic on the Caspian Sea. For the next 20 months while he was held hostage, I met anxiously with my team members to discuss the weekly updates about either progress on his release or silence about his fate. I felt outraged and betrayed because the risk Mr. Erkel faced went beyond what I had expected when I signed up.

This feeling came back to me last week when I heard about the kidnapping of Canadian nurse Laura Archer and four other staff with MSF in the Darfur region of Sudan.

How could this happen to people bringing aid to a country in distress?


When Arjan Erkel was finally released, I breathed a sigh of relief, as did many of my fellow aid workers. Still in my early years of humanitarian work, I felt order had been restored. But that feeling was short-lived.

Just two months later, five MSF staff members were ambushed and killed in Afghanistan. My outrage turned to disbelief and cold numbness. For me, the illusion I had been living of bulletproof principles had been shattered, and order would not be restored this time.

As aid workers have increasingly fallen victim to kidnappings, sexual assaults and killings over the past decade, it's only natural to wonder how we justify taking such risks. The answer is far from simple.

The Payoff

One fact that many aid workers will tell you is that being part of an organization that is in the business of saving lives and restoring dignity feels good; you are reminded that success is possible. This was reaffirmed for me in 2006, when I was in Ivory Coast working on a large hospital project.

Since the prevalence of HIV is as high as 15 per cent in some parts of the country, MSF started many HIV activities there. We established a voluntary counselling and testing centre, but in the first couple of months, fewer than a dozen people came. We worked hard to tell the community about these services, and this number quickly rose. We optimistically set the budget for an average of 300 consultations per month over the year. We reached that number in March, and by October more than 900 people were visiting the centre for counselling each month.

The demand for other activities related to HIV/AIDS rose as well.

We started a program to stop mother-to-child transmission of the virus, so HIV-positive mothers could safely deliver and care for their HIV-negative babies. And antiretroviral drugs were offered to an increasing number of patients, turning around their deteriorating conditions.

In the town, we made contact with people at school assemblies, orphanages, rebel battalions and local groups providing non-medical care for people living with HIV/AIDS. And on Dec. 1, World AIDS Day, more than 600 people came out for the events, including races, speeches from local authorities, live music, dramas and game-show-style quizzes all about HIV.

I believe that our HIV/AIDS intervention in that community significantly improved the lives of thousands of people.

But after working in various projects for six years and seeing the longer-term results of what I had been part of, I realize that it isn't always apparent how our efforts make a difference. I remember one cold day on vacation when I received three e-mails with disheartening news about how my previous work had been erased. One described how a compound I had helped build in south Sudan was looted and destroyed, another how the international team of a tuberculosis project I had started had to be evacuated for their safety, and the third one reported that fighting had broken out, ending a four-year ceasefire in Sri Lanka, where I had earlier helped wrap up our mission in peaceful times. The world I had worked so hard to make a better place had taken two steps backward.

I had a similar feeling when I heard that MSF withdrew staff in Darfur after the kidnapping of the MSF staff members last week. This act will be a devastating blow to the survival of hundreds of thousands of people there.

To many people in towns, villages, refugee camps and city slums, aid organizations do more for the populations than provide food, clean water or health care. For many people defeated by the effects of a conflict, the presence of aid organizations gives hope and restores some dignity by recognizing their plight. Conversely, the evacuation of an aid organization from an area needing its service and recognition, can extinguish that light.

Too Great a Risk

In my most recent posting with MSF, I took over as co-ordinator of an emergency surgical program in Kismayo, Somalia, when three MSF staff had been killed there. In the months after the incident, after the memorials and funeral services, the organization made the difficult decision to end the project. The risk was too great.

The surgical program had given women with labour complications life-saving Caesarian sections. During the eight-month duration of the project, more than 400 (principally obstetric) surgeries and 1,200 emergency consultations were performed by the MSF team of six international and 35 Somali staff.

After MSF closed the program, patients had to pay $350 U.S. for a Caesarian section. For many Somalis, this lifesaving service became financially inaccessible, so a population of 100,000 people were left without this essential service.

We feared that many women would probably die.

Imagine in your home country a collapse of all systems and structures of authority and governance. Imagine violence chasing you and your family out of your homes to walk 100 kilometres to a safer, but desolate area. Imagine carrying some clothes, some food and a cooking pot. Imagine food running out. Imagine drinking water from a dirty river. Imagine children dying from diarrhea. Imagine simple infections leading to amputations or death. Imagine women dying in childbirth. Imagine that all of this is happening while people with the power to do something hold meetings and decide not to intervene.

People shouldn't die from the lack of a 50-cent medication or vaccine. People shouldn't die from the lack of clean water or soap. People shouldn't die from the lack of a proper shelter. But they do.

Over the years, I have seen that a medical and logistics team of just five people supplied with basic medicines, and materials can save the lives of thousands of people.

I have begun to realize that our simple actions do change the world from the perspective of each individual patient who is carried into a clinic and walks out some days afterwards.

The troubles of the world will continue, and my contribution is to be engaged in bringing life-saving aid to individuals in desperate need. The reason for taking action couldn't be any clearer. I accept a degree of personal risk, because I can't accept standing aside in the face of another person's suffering.

I fear that Laura Archer and her colleagues may not be the last aid workers to be kidnapped or harmed, but fortunately their ordeal ended with their release. For most of the aid workers going overseas every year, no critical security incidents will occur and they, too, will return home safely. Though, because of the risks they take, millions of people in precarious situations will be given a better chance of surviving that year. Walking away from this kind of accomplishment would be too hard for many people to justify.

Steve Dennis is an aid worker with Médecins Sans Frontières. When he is not working abroad, he lives in Toronto.

http://www.theglobeandmail.com

March 21, 2009

With his latest denunciation of condom use, Pope Benedict XVI is "sending a message which ultimately kills people," says Stephen Lewis, former Canadian politician and diplomat and world-renowned leader in the fight against HIV/AIDS.

"His words were, frankly, irresponsible and damaging and it was like inviting death," Lewis said Thursday during a visit to Sudbury, where he was invited to deliver a public lecture at Laurentian University.

Speaking to reporters prior to the lecture, Lewis was asked about the latest comments from the pope that have created an international uproar.

Earlier this week, as he launched a tour of Africa, Benedict said, "You can't resolve (the AIDS epidemic) with the distribution of condoms. On the contrary, it increases the problem."

Such a "scientifically inaccurate" statement from the pontiff is "really irresponsible," particularly in Africa -- the global epicentre of the HIV/AIDS epidemic, Lewis said.

The pope's and the Roman Catholic Church's opposition to condom use is well-established, Lewis acknowledged.

However, "when he went on to say that (condoms) aggravate the fight against AIDS, that they exacerbate the fight against AIDS, he's sending a message which ultimately kills people, because the use of condoms is the single, strongest preventive intervention we have against AIDS at the moment," he added.

"That doesn't mean we don't have abstinence . . . and it doesn't mean we don't ask people to be faithful to an individual partner. All of these things come together in prevention. But condoms are absolutely vital and for the pope to do this is really irresponsible."

The Vatican should have a process to sanction popes who advocate such potentially damaging views, Lewis mused ruefully.

"I sometimes think to myself, I wish there were ways of impeaching popes when they go overboard and do such damage, because frankly, amongst the Cardinals there are surely some progressive and thoughtful people who would not entertain such scientifically inaccurate and ideologically rigid positions.

"It's just not helpful."

A former leader of the Ontario New Democratic Party, Lewis was appointed Canada's ambassador to the United Nations in 1984. He later became deputy director of the United Nations Children's Fund (UNICEF) and from 2001 to 2006 he served as the first United Nations Special Envoy for HIV/AIDS in Africa.

Lewis, 71, is a professor with the social sciences faculty at Hamilton's McMaster University and remains active in international development and advocacy work.

He serves as co-director of AIDS-Free World, an international advocacy group and is chairman of the Stephen Lewis Foundation, a charitable organization helping people affected and infected by HIV/AIDS.

http://www.saultstar.com

1. Early Treatment for HIV Act Reintroduced

March 20, 2009

Washington - A bipartisan bill that advocates say will save lives by allowing states to provide Medicaid coverage to low-income, HIV-positive Americans has been reintroduced in Congress.

The bill was filed by Rep. Eliot Engel (D-NY), Speaker Nancy Pelosi (D-CA), and Rep. Ileana Ros-Lehtinen (R-FL) and currently has 44 co-sponsors. A similar bill is expected to be introduced in the U.S. Senate soon.

The legislation addresses a gap in health care coverage for low-income people living with HIV/AIDS.

Despite the fact that Medicaid is the largest single provider of HIV/AIDS care in the U.S., currently most adults with HIV are not eligible for Medicaid until they have progressed to full blown AIDS.

Without Medicaid coverage, many low-income Americans are left without the critical care and medication needed to help slow the progression of the disease.

According to a study conducted by PricewaterhouseCoopers, enactment of this legislation would reduce the death rate among individuals on Medicaid living with HIV/AIDS by half over ten years.

“Now that we have a President who is willing to sign, we urge Congress to pass this common-sense legislation that would save countless lives and taxpayer dollars,” said Human Rights Campaign President Joe Solmonese.

“With early treatment, we’ll be improving the quality of life for HIV-positive Americans; we’ll be reducing the number of infections by lowering viral loads; and we’ll be saving money by treating the infection before it worsens.”

Passage of the bill into law would create significant savings for taxpayers its supporter say, because early treatment for HIV-positive individuals would delay both the need for more expensive forms of treatment and the time at which individuals would become medically disabled. It could also reduce demands on the SSI, Social Security Disability Insurance Savings and Medicaid and Medicare programs.

http://www.365gay.com

2. Kansas House Committee OKs Bill Requiring HIV Tests for Pregnant Women

March 23, 2009

Kansas’s House and Human Services Committee passed a bill on March 18 requiring doctors to test pregnant women and newborn babies for HIV, the Kansas Health Institute News reports. The Senate passed the bill 37 to 3 earlier this month, and it now goes to the state’s full House of Representatives for approval.

“There were some questions raised early on, but they’ve been answered,” said Rep. Brenda Landwehr (R–Wichita), a chairwoman for the committee. She had questioned whether the testing bill would influence positive infants’ health insurance coverage due to their having what’s known as a pre-existing condition.

However, Senate Bill 147’s supporters and the Kansas Department of Health and Environment reasoned that the need to diagnose and prevent new HIV infections in children outweighed concerns over health insurance.

http://www.poz.com

March 23, 2009

Together Rx Access, a multicompany collaborative patient assistance program that provides free prescription drugs for people without health insurance, has widened its eligibility criteria so that 90 percent of uninsured Americans will qualify.

As the number of uninsured Americans has risen in the past decade, so has the number of people living with HIV who do not have access to affordable treatment—including those who do not qualify for Medicaid or AIDS Drug Assistance Programs (ADAP). For these individuals, there are company-led patient assistance programs. But income limits for these programs resulted in many people falling through the cracks.

The Together Rx program, which provides free prescription drugs—including, but not limited to antiretroviral treatments—reports it has increased its income limits. Cooperating companies that make HIV medications include Abbott, GlaxoSmithKlein, Pfizer and Tibotec. Now, a single person making up to $45,000 per year qualifies for the program, up from $30,000 per year. For a family of two, the limit has increased from $40,000 to $60,000. For a family of three, the limit has increased from $50,000 to $75,000.

http://www.poz.com

March 24, 2009

"Nearly 30 years into the AIDS epidemic, we are able to access our progress in tackling the disease with both increased knowledge and the benefit of hindsight," former UNAIDS Executive Director Peter Piot of Imperial College London, who also serves as an adviser on global health strategy to the Bill & Melinda Gates Foundation; Michel Kazatchkine, executive director of the Global Fund To Fight AIDS, Tuberculosis and Malaria; Mark Dybul of the O'Neill Institute for National and Global Health Law at Georgetown University and former U.S. Global AIDS Coordinator; and Julian Lob-Levyt of the GAVI Alliance write in a Lancet opinion piece. They add that the piece aims to examine "what we -- the international community -- got right, what we got wrong, and why we need to urgently dispel several emerging myths about the epidemic and the global response to it."

According to the authors, when "HIV was emerging in the early 1980s, we clearly underestimated the global effect that the disease would have, and that in only a few decades, tens of millions of people worldwide would become infected." They add, "The epidemic nowadays is the result of what 30 years ago was an unpredictable -- but tremendously potent -- combination of intimate personal behaviors ... and socioeconomic factors ... that have affected nearly every country worldwide." In addition, the international community underestimated "the extent to which stigma and discrimination -- against people living with HIV/AIDS and those most vulnerable to it -- would remain formidable obstacles to tackling AIDS," the authors write, adding that the "sense of urgency and solidarity that would eventually develop in the global AIDS epidemic, leading to an unusual convergence of political will, money and science" also was underestimated.

Other aspects of the HIV/AIDS pandemic were overestimated, the authors write. They add that despite innovations and successes regarding antiretroviral treatment, "we have also overestimated our capacity to devise technological solutions to prevent HIV," and "continued investments in new prevention technology remain a crucial part of the AIDS research agenda."

The author's point to the common myth that HIV prevention has not been successful overall -- which they say is contradicted by evidence it has been effective in several countries, adding that prevention is about behavior in addition to technology. They add that sustaining changes in sexual behavior "remains a major challenge," citing the possible "complacency about AIDS and the sense that a treatable disease is somehow less threatening than are other diseases."

There is also a "recurrent" myth that there is one "silver-bullet" solution to HIV prevention; however, "no approach will be enough on its own, and the promotion of one solution is ... irresponsible," the authors write. They continue that another "prevailing" myth is that there is little heterosexual transmission of HIV outside Africa and note that HIV transmission among women is rising worldwide, with "[m]ethods of transmission and affected groups" being "many and varied."

The authors write, "Alarmingly, a myth has begun to emerge that too much money is spent on AIDS," as countries face new financial difficulties while "competing for the attention of political leaders and donors." The myth that investments in AIDS efforts have been at the expense of underfunded health systems also needs to be dispelled, the authors write, adding that funds for HIV/AIDS efforts "are making a major contribution to the strengthening of health systems." The authors also address the myth that HIV/AIDS "has somehow been solved, writing, "We need to recognize that AIDS is a long-term event. Tackling it is complex, but our successes so far indicate what is possible." Increased efforts to examine epidemiological trends, "develop long lasting links with broader efforts to strengthen health systems and health workforces," continue investment in research, and make a "serious, concerted effort" to address stigma and discrimination are needed to "be anywhere close to the point at which we can truthfully say the fight against AIDS is being won" (Piot et. al, Lancet, 3/20)

http://www.kaisernetwork.org

March 27, 2009


"Safe sex is the best way to protect against HIV infection."

The figures, which are estimated because the agency has not got all the data from clinics, showed overall new diagnoses had fallen from 7,660 in 2007.

Among gay men there was a slightly larger fall proportionally from 3,050 to 2,830, but it was still the second largest number since recording began in the 1990s.

The HPA also expressed concern about the high number of late diagnoses.

A fifth of cases among gay men were beyond the point at which treatment should have begun, raising the risk of death within the first year.

Proportion

Deborah Jack, chief executive of the National Aids Trust said: 'We welcome the fall in the number of new diagnoses of HIV - but we need to wait to see whether the trend is really downwards or still plateauing.

"But most importantly, we must remember that gay and bisexual men are still the people most affected by HIV here in the UK - with one 1 in 20 gay and bisexual men infected with HIV.

"If that proportion of the general UK population had HIV it would be headline news."

She also said it was worrying that the number of heterosexual cases from sex in the UK - most of the heterosexual diagnoses are from sex abroad, mostly within African communities - showed signs of rising.

In 2008 there were just over 1,000 new cases - up by 110 from 2007.

However, the charity said it was still a tiny proportion of the people engaging in heterosexual sex.

Lisa Power, of the HIV charity Terrence Higgins Trust, said: "Numbers of people diagnosed with HIV are rising for many reasons.

"More people are getting tested, which is good. But some people don't realise they could be at risk, and others take risks despite knowing them. HIV is not a risk worth taking."

http://news.bbc.co.uk

March 22, 2009

Kigali — 34 percent of deaths of Rwandans above the age of five are caused by HIV/AIDS and other related illnesses like Tuberculosis (TB) or prolonged Malaria each year.

The revelations were made yesterday by the Minister of Health, Dr Richard Sezibera, ahead of the Health Week.

He disclosed that during the coming week, special emphasis will be made on the immunization of children and awareness creation around the parent's collective role of upholding health status among families.

"Women should bring their children for medical treatment during this week and their husbands must also play a helping role. Bringing up children is a collective responsibility by both parents," Sezibera said.

"As much as we try to streamline our health services, individuals should desist from bad practices like spitting or coughing irresponsibly because this contributes to the spread of disease," he said.

The Ministry of Health will also build more maternity wards and boost human resource in health centres as well as empower health mobilizers at the community level, he announced.

In a bid to bring health services closer to the population, the ministry has also unveiled plans to have at least three ambulances in each district to ease emergencies.

Hon. Liberata Kayitesi, a member of the Parliamentary Committee on Public Welfare, underscored the importance of awareness campaigns despite the shortcomings that have hampered the process.

"However, awareness alone is not enough practical solutions to the health problem like periodically carrying out tests or going for medical checkups in case of a suspected infection are necessary," Kayitesi said.

During this week, special emphasis will be on the fight against TB and other HIV related infections.

By SamNikrunrnziza, http://allafrica.com

March 24, 2009

Washington, DC - Today marks World Tuberculosis Day, and I join others around the world in saying “I am stopping TB.”

Tuberculosis (TB) kills almost 5000 people each day, and is the leading cause of death for people living with HIV/AIDS. According to the World Health Organization, almost 40% of TB cases are not properly detected and treated. While treatment for TB exists, more and more individuals are being diagnosed with multidrug-resistant (MDR) TB or extensively drug-resistant (XDR) TB, which are difficult and expensive to treat.

Our government is taking steps to address the global burden of TB. The U.S. Government is the largest contributor to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which has detected and treated over 4 million cases of TB. The President's Emergency Plan for AIDS Relief (PEPFAR) is working to improve the diagnosis and treatment of TB for co-infected persons, and is engaged in infection control efforts to prevent new cases of TB. In addition, the United States Agency for International Development (USAID) has tuberculosis programs in more than 35 countries and is working to strengthen the capacity of health systems to identify, detect and control TB, particularly MDR and XDR TB
.
While much has been accomplished in the fight against this disease, there is still much more to be done if we are to meet the Millennium Development Goal of halting and reversing the spread of TB by 2015. I strongly believe the State Department should continue and expand its commitment to reducing the global burden of TB, and I look forward to working to improve the global response to this and other leading causes of death for the world's poorest communities.

http://www.state.gov/secretary

Around one-quarter of deaths in people with HIV worldwide were caused by TB in 2007, the World Health Organization said today. Around 450,000 people with HIV died of TB in 2007, WHO estimates, and there were 1.4 million HIV-positive TB cases.

HIV-positive people are around 20 times more likely to develop TB than HIV-negative people in countries with a high HIV prevalence.

The figures were released today in WHO’s 2009 Global tuberculosis control report, and represent a substantial upward revision of previous estimates.

The high burden of deaths in people with HIV due to TB is especially alarming because TB is preventable. Early diagnosis and treatment now results in a cure rate above 85% according to reports from global TB programmes, yet rates of TB screening in people with HIV are low.

People with HIV are not being offered isoniazid preventive therapy on the scale necessary to prevent new cases of TB in people previously exposed to TB, and the provision of antiretroviral therapy is failing to keep pace with HIV diagnoses in TB cases, the WHO report notes.

WHO says that although the estimate of TB deaths is double the number it published in 2006, this does not represent a doubling in TB cases since 2006. Instead, the organisation’s epidemiologists believe their new estimate is a more accurate picture of the global TB burden among people with HIV, because it draws on findings from more extensive HIV testing among people diagnosed with TB in 64 countries during 2007-2008.

Of the fifteen countries with the highest incidence of TB in HIV-positive people, all but one are in sub-Saharan Africa, with southern Africa leading the way.

In Lesotho, Swaziland, South Africa, Zimbabwe, Namibia and Botswana the incidence of HIV-positive TB cases is above 400 cases per 100,000 people, while the prevalence of HIV in new TB cases is above 50% in the southern African region. Overall, 79% of HIV-positive TB cases are estimated to occur in sub-Saharan Africa.

WHO says that overall progress towards diagnosing HIV in TB patients is good, with 14 African countries able to report the HIV status of more than half of TB cases in 2007.

Nevertheless WHO estimates that only 37% of notified TB cases across Africa as a whole were tested for HIV in 2007, and HIV case detection in DOTS programmes needs to be expanded.

However TB screening among people already diagnosed with HIV continues to be low, WHO says, and provision of isoniazid preventive therapy is extremely limited: only 30,000 people with HIV are estimated to have begun a course of isoniazid in 2007 (4.8% of those eligible) and just 14% of HIV-positive people in care have been screened for TB.

Provision of antiretroviral therapy to HIV-positive TB patients is also lagging behind rates of HIV diagnosis in TB patients. Just one-third of HIV-positive TB patients started antiretroviral therapy in 2007, perhaps because the number of health facilities offering antiretroviral therapy is not keeping pace with the expansion of provider-initiated counselling and testing in TB programmes.

WHO estimates that there were five TB treatment facilities for every ARV clinic in eight focus countries that account for 18% of global HIV-positive TB cases in 2007.

WHO also reported on progress towards integration of TB/HIV activities at country level, and collated monitoring data on implementation of some key actions it recommended in 2007 called the Three I’s – intensified case finding, isoniazid preventive therapy and infection control - that are aimed at reducing the burden of TB in people with HIV.

While 156 countries got a 90%+ score for their completeness of reporting on mechanisms for collaboration and joint policy development, when it came to the practical fruits of this policy work, more than half of countries filed seriously incomplete details of their progress towards intensified TB case finding in people with HIV or provision of isoniazid preventive therapy. Details of infection control activities were also frequently lacking.

By Keith Alcorn, www.aidsmap.com

By Michael Carter, www.aidsmap.com

By Carole Leach-Lemens, www.aidsmap.com

March 20, 2009

Tenofovir (found in Viread, Truvada and Atripla) is associated with an increased risk for kidney tube dysfunction in people with HIV, notably as they age, according to a study published in the March 27 issue of AIDS. People with damaged kidney tubes can ultimately have problems not only with their kidneys, but also with bone mineral absorption.

Because tenofovir is chemically similar to other drugs known to cause kidney toxicity, researchers have carefully searched for signs of kidney trouble in people taking the drug. Some people on tenofovir have developed severe kidney problems, but these cases are very rare. Dysfunction of the tubes within the kidney—responsible for transporting chemicals from the blood to urine—has also been a concern with tenofovir and has been documented in various studies.

To further explore whether tenofovir is associated with tubular dysfunction, Pablo Labarga, MD, PhD, from the Infectious Disease Department at the Hospital Carlos III in Madrid, and his colleagues conducted blood tests of 283 people living with HIV. Of those patients, 153 were on antiretroviral (ARV) therapy that included tenofovir, 49 were on ARV therapy and had no history of tenofovir use, and 81 had never taken ARVs. The patients were similar in most factors that are associated with kidney function, except that those not on ARVs were younger and people taking tenofovir had a higher body weight than the rest and were more likely to be infected with hepatitis C virus (HCV) or hepatitis B virus (HBV).

Labarga’s team found that 22 percent of those on tenofovir had tubular dysfunction, as did 6 percent of those taking ARV drugs without tenofovir and 12 percent of those with no history of ARV use. After accounting for all other factors, the risks that remained significant predictors of tubular dysfunction were tenofovir and older age.

Though the authors did not find that tubular dysfunction was associated with other kidney toxicity, they are urging health care providers to closely monitor kidney function and bone mineral levels in people taking tenofovir. This is because more people with HIV are entering their 50s and 60s and because tubular dysfunction may further increase the risk of low bone mineral density—osteopenia and osteoporosis—over longer periods of time.

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March 24, 2009

People who regularly miss doses of their antiretroviral (ARV) regimen have an increased risk of death, according to a study published in the April issue of the Journal of Acquired Immune Deficiency Syndromes.

When combination ARV therapy was introduced in 1995 and 1996, it quickly became clear that a person’s ability to take all of his or her doses as prescribed was vital to the regimen’s success. Studies of patient adherence found that anything less than 95 percent of doses taken correctly substantially increased the risk of treatment failure and the development of drug resistance. More recently, however, some researchers have questioned whether the more potent and tolerable regimens available today may require less strict adherence.

To determine the impact of adherence on modern ARV combinations, Vivian Lima, PhD, from the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, and her colleagues studied the medical records of 903 HIV-positive patients receiving care at a large Vancouver HIV clinic. Most of the patients were male, and 25 percent had a history of injection drug use (IDU). Roughly 65 percent started on a regimen containing a non-nucleoside reverse transcriptase inhibitor (NNRTI)—the most common being Viramune (nevirapine)—and 35 percent started regimens containing a protease inhibitor boosted by low-dose Norvir (ritonavir)—the most common being Kaletra (lopinavir plus ritonavir). Average follow-up was nearly three years.

Lima and her colleagues assessed adherence by comparing the patients’ refill records at the pharmacy. Her team found that 40 percent of the patients had adherence rates of less than 95 percent (for example, missing more than one dose per month among those taking once-daily treatment). Moreover, there was an overall decrease in adherence over time, from an average rate of 79 percent of doses in the first six months to 72 percent by the third year.

Though the overall death rate was low, Lima’s team found that people with less than 95 percent adherence were three times as likely to die from any cause. They also found that people on a regimen of efavirenz (found in Sustiva and Atripla) were nearly seven times as likely to die if they had poor adherence. It should be acknowledged that other studies have found high rates of treatment success with efavirenz, even in patients with less than 95 percent adherence.

Though the authors attempted to control for influential factors, such as CD4 count and viral load before starting ARV therapy, they acknowledge that they did not assess whether people with a history of IDU were currently active drug users. This is key, because active drug use is associated with higher mortality rates and might have influenced the study results.

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March 25, 2009

Neurocognitive disorders—problems with thinking, memory and coordination—may lead to, and be caused by, poor adherence in older HIV-positive adults, according to a study published in the April issue of The American Journal of Geriatric Psychiatry.

A number of studies have found that, on average, older HIV-positive adults are less likely to miss doses of their antiretroviral (ARV) medication than adults who are younger. An increasing number of studies, however, are finding high rates of neurocognitive disorders in older people with HIV. To determine whether neurocognitive problems may affect adherence to ARV therapy, Mark Ettenhofer, PhD, from the Department of Psychiatry and Behavioral Sciences at the University of California in Los Angeles, and his colleagues conducted neurological tests and assessed adherence in 431 HIV-positive adults in the LA area.

Neurocognitive function was assessed by measuring participants’ information processing speed, their ability to learn and memorize, their aptitude with language and their physical coordination. Medication adherence was measured using microchip-embedded pill bottle caps.

As with previous studies, Ettenhofer and his colleagues found that participants older than 50 had better treatment adherence, on average, than participants younger than 50. They also found, however, that reduced neurocognitive function was strongly associated with poor adherence in older adults, but not in younger adults. Older adults were also more likely to have lower CD4 counts and report drug use.

The authors conclude that health care providers and people with HIV older than 50 should be on the lookout for neurocognitive problems and carefully evaluate and manage adherence. They point out that although cognitive problems might lower adherence, the converse might also be true: that poor adherence might exacerbate or lead to neurocognitive problems.

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There's nothing like hearing the results of studies directly from those who actually conducted the research. In this interview, you'll meet one of these impressive HIV researchers and read his explanation of a study he presented at CROI 2009.

I'm Rohan Hazra. I work at the Pediatric, Adolescent and Maternal AIDS Branch of the National Institute of Child Health and Human Development, which is one of the institutes that makes up the [U.S.] National Institutes of Health.

We have a project called PHACS, the Pediatric HIV/AIDS Cohort Study, which is aiming to enroll 450 HIV-infected children between the ages of 7 and 16. All of these children acquired HIV from their mother; they are perinatally infected. We're looking at long-term outcomes in these children related to cognitive function, cardiac function, liver disease, kidney disease, bone health.

We have a number of posters in this meeting addressing some of those issues, but this particular work actually grew out of the work that's at the next poster,1 which is looking at trends in treatment and how they have changed over time, as new drugs have been developed, and some that end up being approved for children [while] some aren't. As we were doing that analysis, we realized that 5 percent of the children in this project, in the PHACS project, were not on any antiretrovirals when they enrolled on the study. So we thought it would be interesting to see: Is there something about those children that would be interesting to report?2

As I mentioned, it's 5 percent of the cohort. At the time that we did the data analysis, that was 12 children. But when we looked at their criteria, realized that in fact some of them may well actually need to be on treatment but, for whatever reason, were not. We wanted to look more closely at those that did not, at this point, meet criteria for treatment. So we defined those criteria accordingly: They needed to have been off antiretrovirals for six months or more, have a good CD4 count and have no clinical progression of disease.

Then we put together a fair amount of information on them, [which] showed a number of things. We are enrolling children 7 to 16, so the median age of this group was 14 and a half. About half were female. Half were black. Most of them did not have extensive clinical disease: One-third of them had what we call CDC [U.S. Centers for Disease Control and Prevention] Category B or C disease. All of them had been treated in the past with HAART, but while on this protocol, for whatever reasons, were not on antiretrovirals. They'd had a total of close to nine years of treatment, and now had been off for four to five years.

Despite being off treatment altogether for two years, they basically have maintained a relatively good CD4 count: Most of them have CD4 counts in the 500s to 600s. They have positive viral loads, but they are low to moderate.

What we're trying to do is say that these children do exist. I think it should hopefully prompt investigators to think about designing very careful clinical trials to see whether we can give our patients, especially as they get into their teenage years and they're dealing with a lot of other stresses in their lives, and have a lot of problems with adherence to medication; potentially, could we design a careful clinical trial to actually look at safely discontinuing treatment for a short period of time -- for a couple of years, while they are growing and developing? With the idea that, ultimately, they are going to need -- at least based on what we know now -- lifelong antiretroviral treatment?

This [study does] not [answer] that. This is purely a description of what we're seeing in this cohort. But I hope that it will prompt some discussion and potential[ly result in] carefully designed clinical studies to look at this as an option for some children, as they age into teenage years and adulthood.

Is the issue that, since the recommendation is to treat all children, we can't tell who is a non-progressor, because there is no test right now that would be able to predict whether a child's immune system can handle HIV by itself? But you think that the children you've isolated in this study are those non-progressors?

Correct. I think there's been a lot of work presented at this conference on genetic markers that are potentially associated with being able to control HIV and maintain a CD4 count. We don't have any of that information on this group. But I think it's a very good point that we would have the ability to do it. Because it's designed within the study to be able to look at those kinds of things, we would potentially be able to look at something like that.

Could it be that these children are not non-progressors, but that something happened as a result of starting treatment so early in their HIV disease that enabled them to later not have to take treatment?

I doubt that. The numbers that I stated about the time that they started ARVs and the median duration of treatment are very similar to the rest of the group, which has continued on treatment.

To the point that you made: In this country, and increasingly around the world, the push is, when a baby or young child is diagnosed, almost all of them end up on treatment. I think in the United States, we've been quite aggressive with that. Almost all diagnosed infants and young children in this country used to go on treatment. Something we should probably make sure of, because I think it's a good question, is that it's not that there was something different about the trajectory of treatment in these children. From what I can remember, they did not differ from the rest of the group that had to continue on treatment.

What are some of the reasons that these children discontinued treatment?

This is actually a piece of the study; we had to go back and ask the sites for this information. They then went back to their medical records to try to piece this out. It turned out, in most of [these children], that the person looking after them really felt that they didn't need antiretrovirals. I think there was a hint, even while they were on treatment -- they didn't seem to be having illnesses the way the other children were. They were able to very easily get their CD4 counts up and keep their viral loads down. For whatever reason, the major reason for why they were not on treatment was the sense of the caregiver, the clinician, that they didn't seem to need antiretroviral treatment.

This is, I believe, the first time this has ever been described.

It's interesting; it's one of the reasons we wanted to do it. It's something that all of us, as clinicians -- and, in fact, about half the people that have come by the poster today -- have said: "Oh, we have these kids, as well, in our practices." I think it's something that we have all recognized. But you're exactly right: There's not been extensive description of it. That's what we were trying to do, in a small way.

I do want to say that this phenomenon is potentially much, much more common in the developing world, because of the fact that, until recently, the only children that would survive into adolescence were kids that were long-term non-progressors. If they didn't have treatment beforehand, unfortunately most HIV-infected children would die. It would be then that you would have a lot of adolescents that then make up a much larger percentage of the population.

I think it's something that we as clinicians have recognized, but it's just not been something that we have been able to systematically describe. This project has given us that opportunity.

What percentage of children are thought to be non-progressors? Is it known? Do we know from the developing world?

I don't think we know. [In the United States], would we say 5%? I have to say, as a clinician, and from talking to some of the other clinicians, that seems about right. Some folks say they have maybe 10%. But what we're always missing is the denominator. Here, we have probably a better sense because at least it's from a whole cohort. But there may be some bias as to who actually is enrolled into this study: Either these children are overrepresented in this study because they are doing well, or they are underrepresented because the kids that are not on treatment are, in fact, not seeking care regularly, and therefore they don't show up at the sites to actually be eligible., I don't think we know, but I think most of us would say it's somewhere in the 5% to 10% range.

What are your next steps?

The big thing about this project is really trying to identify overall how these youth are surviving -- and, I would like to hope, thriving, despite their HIV and their transition into the late teen years and young adulthood. That's the larger project.

I think with this particular project, you've raised some of the issues. I think we need to tease out a little bit more what are the factors about these nine youths that have allowed them to do [well despite not receiving HIV treatment]. I think [we should] potentially consider some of the genetic questions that you have asked.

I think we should have a lot of discussion, but again, I would stress this is not something to try at home. I think that we would want to just think about: Is there a carefully designed clinical trial that we could do to see if we can do this in a systematic fashion? Because I think these are real issues for youth, in terms of medication, fatigue, adherence. Usually it's in these years that responsibility for medication administration switches from the parent to the child, as well. Plus, there are just a lot of issues going on in adolescence. I think being able to have the option of considering treatment cessation temporarily for these youths would be a very good one, within the clinical armamentarium.

Thank you very much.

Thank you.

This transcript has been edited for clarity.

References
Van Dyke R, Patel K, Read J, et al, and the Pediatric HIV/AIDS Cohort Study. ART among children with perinatally acquired HIV infection: temporal changes in ART and virologic and immunologic outcomes in the Pediatric HIV/AIDS Cohort Study Adolescent Master Protocol. In: Program and abstracts of the 16th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2009; Montréal, Canada. Abstract 901.
Siberry G, Patel K, Burchett S, et al, and the Pediatric HIV/AIDS Cohort Study. Discontinuation of ART among children with perinatally acquired HIV infection. In: Program and abstracts of the 16th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2009; Montréal, Canada. Abstract 900.
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