25 MARCH 2011, VOLUME 12, ISSUE 12

Efforts to fight the spread of HIV/AIDS are being held back by health workers' reluctance to treat high-risk groups including transsexuals, gays and bisexuals, officials have warned. Rohana Manggala, head of the Jakarta branch of the Commission on HIV/AIDS Prevention (KPA), said on Thursday that health facilities in the capital needed to be more inclusive. ...To tackle this problem, she said Governor Fauzi Bowo had asked the KPA to draft policies that would allow transsexuals, gays and bisexuals to access health services more freely. Rohana said the KPA would provide sensitivity training beginning in the middle of the year at five selected puskesmas, community health centers, in each of Jakarta's five municipalities. She said health workers would be given a deeper understanding about the affected minority groups and how to treat them without discomfort or prejudice. ...The Health Ministry reported that as of December, there were more than 24,000 AIDS cases in Indonesia, of which about 4,000 were in Jakarta. In 2008, the United Nations estimated that as many as 300,000 Indonesians were living with HIV/AIDS.

More than two decades after the first case of AIDS in a Japanese patient was officially reported by the health ministry's National AIDS Surveillance Committee in 1985, HIV/AIDS seems to have become a disease of the past. With much less media coverage, people have become complacent about the issue, experts say... While the total numbers of newly reported HIV positive people and AIDS patients are still low in Japan compared with other countries, the number of newly HIV-infected people in Japan has doubled in the past decade. Since 2004, the number of people newly reported with HIV has topped 1,000. In 1990, 97 people were newly found to be infected. This has increased by more than a factor of 15 to 1,503 in 2010, a report by the health ministry said. It also said that in 2010, a record 453 people developed AIDS. The figures are alarming when compared with a decline in global data... In Japan, about 50 percent of HIV-positive people, excluding those who developed AIDS symptoms, were infected through homosexual sexual contact and about 30 percent were infected through heterosexual sexual contact, as of December 2010, according to the government's National AIDS Surveillance Committee. What's also alarming is the slight increase in people who found out about their infections after they developed AIDS symptoms, said Sawazaki of JFAP. In 2010, about 30 percent of new HIV carriers found out about the infection after they developed AIDS symptoms. The percentage has increased two years in a row since 2008.

The African nation of Rwanda recently set a goal of circumcising an estimated two million adult men by the end of 2012 to fight the spread of HIV, and is investigating a new nonsurgical device that is said to allow practitioners to perform the procedure in less than four minutes--without anesthesia. The patent pending PrePex device includes an elastic mechanism that fits around an inner ring, trapping the penis foreskin--the loose fold of skin that covers its glans--which cuts its blood supply. The foreskin thereby dries up and is removed after a week. Neither anesthetics nor sterile settings nor sutures are required--and no blood is lost, according to health authorities studying the device. After the procedure the Rwandan government guidelines suggest that patients abstain from having sex for six weeks, which is also the case after conventional surgery. This device, it is hoped, could help scale up Rwanda's mass circumcision initiative...

Campaigns of mass circumcision have thus been launched in various countries, including Rwanda, where HIV prevalence is 3 percent but only 12 percent of adult males are currently circumcised. "If we only circumcise newborns, the effects will start in 15 years. We have to face the problem now," says Agnes Binagwaho, permanent secretary of Rwanda's Ministry of Health. "We are now offering, alongside counseling, testing and condom distribution an additional means of lowering transmission. It's a comprehensive approach." The major obstacle to adult circumcision in most sub-Saharan countries remains the lack of medical infrastructures and trained health professionals to perform the operation. To overcome this, some countries such as Kenya now allow nurses to perform the surgical procedure. In others, like South Africa, the different stages are divided among nurses and physicians, to decrease physician time spent per procedure. Now, the concept of a device that can bypass the need for any anesthesia or sutures is also raising interest. "There's absolutely no doubt that if one can perform male circumcision without anesthesia, you save time, money and it requires less expertise," says Kim Eva Dickson, senior adviser in WHO's HIV/AIDS department.

Engineered, virus-like particles that would latch onto HIV, exploit its genes, stop it from replicating and then get transmitted in the same way as HIV are being proposed as a new way of stopping the epidemic. Biochemist Leor Weinberger and colleagues at the University of California, San Diego and UCLA, estimate that what they call 'Therapeutic Interfering Particles' have the potential to reduce HIV prevalence 30-fold over 50 years in the worst epidemics in sub-Saharan Africa, compared with a halving of prevalence in the most optimistic alternative scenarios of antiretroviral use or use of a successful vaccine. The findings are published in the March 17 issue of PLoS Computational Biology. "TIPs are molecular parasites that 'piggyback' on HIV to spread between individuals," Weinberger said. TIPs are a form of gene therapy, in that they would incorporate into human cells and use human cells, together with HIV's genes, in order to reproduce....

... For the time being the research group's findings are based on a mathematical model, and the only evidence that the idea might work comes from animal studies that show that a lentiviral vector similar to a TIP is taken up by HIV and subsequently inhibits HIV replication. Weinberger acknowledges that an infectious treatment raises ethical concerns and is working with bioethicists to explore the unique issues associated with any use of TIPs in more detail. The researchers say that any research into the human use of this potential technology will have to proceed cautiously, both to examine the genetic safety of a lentiviral vector that can insert itself into human cells, and also to test how the TIP would evolve, whether it would be cleared by `carriers` and whether the TIP might have unexpected interactions with the human immune system. In particular, animal studies will need to test whether TIPs might paradoxically drive up HIV replication, or cause mutations in human cells.

Reference
Metzger VT, Lloyd-Smith JO, Weinberger LS. Autonomous targeting of infectious superspreaders using engineered transmissable therapies. PLoS Computational Biology, March 17, 2011.

The number of diagnosed cases of the human immunodeficiency virus on the Navajo Nation has jumped in recent years, prompting health officials to expand services... According to reports from the Navajo Area Indian Health Service, the number of new cases of HIV diagnosed per year in IHS hospitals and health clinics has more than doubled in the last decade. In 2000, approximately 15 cases of HIV were diagnosed per year at Navajo facilities. In 2009, however, 40 new cases were diagnosed, and 35 were diagnosed in 2010…. "HIV is a considerable problem in Indian Country," said Dr. Yvette Roubideaux, director of the Indian Health Service. "American Indians also face more risk factors than some other groups, such as higher rates of sexually transmitted diseases and substance use.

Speaking Tuesday at a regional summit on HIV/AIDS, Bahamian Minister of Health Dr. Hubert Minnis said prevention efforts targeting undocumented immigrants are hindered by their fear of apprehension, language barriers, stigma, lack of economic power, and lack of awareness regarding at-risk behaviors. Minnis was the keynote speaker at the Caribbean Regional HIV Prevention Summit on the Most At-Risk Persons and Other Vulnerable Populations, held in Nassau. He said other high-risk groups in the Bahamas include: young people, men who have sex with men, commercial sex workers, and people age 50 and older. While health care providers face "significant" challenges in trying to reach these groups, government efforts are helping them in many ways, he said.

"Our focus has always been on prevention of transmission of HIV and the comprehensive care of the individuals infected with HIV, so access to health care, regardless of immigration status, is a tenet of the Ministry of Health," said Minnis. "Antenatal care, including the provision of antiretroviral therapy, is provided free of charge to all public patients," noted Minnis. "This has also been extended to all registered HIV-positive patients in both the public and private health care sectors." The minister said the success of Bahamas' National HIV/AIDS Program, founded 23 years ago, is due to its focus on "oversight, planning, training, coordination and evaluation of the national response to HIV/AIDS." The Caribbean, he observed, is the "second-most HIV-affected region in the world." (The Ministry of Health co-sponsored the summit with the US President's Emergency Plan for AIDS Relief.)

The Financial Services Committee of the US House of Representatives passed an amendment Tuesday that "urges Treasury to advocate that governments receiving assistance from the multilateral development institutions do not engage in gross violations of human rights, for example, the denial of freedom of religion, including the right to choose one's own religion, and physical persecution based on sexual orientation or gender identity." Rep. Barney Frank (D-Mass.), who introduced the measure, cited Uganda, which benefits from the Heavily Indebted Poor Countries program, as an example of a nation that abuses its LGBT citizens. Frank said the United States should not support providing multilateral bank development funds "to the governments of countries which engage in the physical persecution of people because of their religious beliefs, sexual orientation or gender identity." The amendment will be added to a bill that outlines budget priorities regarding issues under the committee's jurisdiction. Frank's office said the bill passed with nearly unanimous support, which may win it support in the Budget Committee and the full House.

CAPE TOWN - Delays in registering new generic drugs with the Medicines Control Council were costing it "hundreds of millions of rands" in unrealised sales, SA's fourth-biggest pharmaceutical company, Cipla Medpro, said yesterday. Cipla Medpro was ranked fourth by value last year by independent research company IMS, behind Aspen Pharmacare, Sanofi-Aventis and AstraZeneca. Cipla Medpro CEO Jerome Smith said his company was waiting up to three years to get new products registered with the council. Presenting the company's results for the year to December, he told analysts Cipla Medpro had 274 dossiers pending registration at the council, and expected only 25 to be registered this year. Last year the council registered 18 new Cipla Medpro products. "The more we register, the more we sell. So when we don't, it's a hassle. The longer it doesn't get to market, the bigger the cost to our company," Mr Smith said...

He said Cipla Medpro had an agreement with the Technology Innovation Agency (TIA) to manufacture and distribute a microbicide containing tenofovir gel in Africa should further research show it to be a safe and effective way to combat HIV. The TIA, a government agency established by the Science and Technology Department, holds a licence from nonprofit agency Conrad for the African rights to the product...

The "International Conference on Local Pharmaceutical production in Africa" event [sponsored by the German Ministry of Economic Cooperation and Development, April 4-6, Cape Town] will provide a forum at which pharma companies, associations and health ministries can examine drugmaking in the continent and work to reduce dependence on foreign production. In-Pharmatechnologist.com spoke with UNCTAD legal expert Christoph Spennemann who explained that local manufacturing will help improve the lives of the millions of patients across Africa who lack health insurance and public health provision. "Currently almost two billion people lack access to medicines in developing countries [and although] it is true that the major pharmaceutical companies are making laudable efforts [but] the problem remains." Spennemann also suggested that the recent introduction of pharmaceutical patent protection in India, which is still the major exporter of drugs to Africa, could result in higher prices for essential medicines such as ARVs and malaria treatments. "India may become less important as a source of affordable drugs and that is one of the reasons why some African countries re looking into the possibility of producing drugs locally." The biggest manufacturing challenge, Spennemann continued, is ensuring the quality of drugs that are produced.

Only a handful of organisations organise HIV tests in schools in South Africa, the country hardest-hit by the virus that infects 5.7 of the 48 million population. Nine percent of people younger than 20 have HIV. Hoping to improve treatment for youths, the government in February decided to expand testing, proposing that all students older than 12 get checked. Children's advocates immediately called for caution, fearing that students would feel forced to take the test, even if they weren't emotionally prepared for a positive result... About one quarter of the students offered testing by Mpilonhle declined to take it. At Madwaleni high school, one 17-year-old girl turned down the test. Her face drawn and downcast, she said she had sex with an older man and fears the possible result. "I am afraid," she said. "Once I know that I am positive, my school work will be affected." Mpilonhle's top educator Gugu Zulu said such stories highlight the need for testing in schools. "You can't pretend that these teenagers are not sexually active, when they are. They are no longer innocent angels," she said. Half of South Africans lose their virginity at age 16, and girls sometimes have relations with older men in exchange for small gifts. "Because most parents are unemployed, to get things, the kids will go out with sugar daddies to get money from them," said Andile Zulu, a social worker for Mpilonhle. That leaves girls more exposed to the virus. Six percent of 12th-grade girls tested by the group were positive, compared to less than three of boys in the same grade.

The United Nations health agency today released its first ever list of the most vital medicines for saving the lives of mothers and children, and stressed the need to ensure their availability in developing countries. The list of the top 30 medicines includes oxytocin, a drug used to treat severe bleeding after childbirth, the leading cause of maternal death, as well as simple antibiotics to treat pneumonia, which kills an estimated 1.6 million children under the age of five every year... Other medicines on the list include those for treating high blood pressure and sexually transmitted infections among women, as well as diarrhoea, malaria and AIDS-related illness among children.

As Congress moves closer to reforming a patent system that often has become an impediment to the innovation it is meant to inspire, many in America's innovation community - including garage entrepreneurs and venture capitalists - are worried that the reforms are only going to make matters worse. "The way the bill came out really disadvantages small start-up companies," said Kelly Slone, an analyst at the National Venture Capital Association, which is among a diverse group of opponents to the America Invents Act of 2011... The association, the nation's largest trade group for early-stage investors, complains that the proposal moving through Congress creates new ways for third-party outsiders to challenge the validity of an issued patent, a move that allows established companies with teams of product developers and litigation war chests to "string out small companies until they are out of money," Slone said. The proposed legislation cleared the U.S. Senate this month and is awaiting action in the House of Representatives. One of its most controversial provisions is a "first to file" rule, which would grant patent rights to whoever gets to the Patent Office first - terminating the existing "first to invent" practice, which honors applicants who can document that they were first to conceive an idea or technology. A related provision imposes new risks for entrepreneurs who explore business partners, prototypes and investors during the 12 months that precede an application, a "grace period" during which current law offers some protection that would not exist under the reform proposal. The proposal could force start-ups to race to the U.S. Patent and Trademark Office with a flood of premature and poor-quality applications - even as patent examiners remain heavily overburdened, with a backlog of more than 1.2 million patent applications awaiting resolution at the start of this year.

PABBO/AMURU - Internally displaced people in northern Uganda face a difficult choice - whether to return to their ancestral villages or stay in camps hoping for better access to healthcare, as antiretroviral (ARV) drugs are in short supply. "Going back to the village to me means committing suicide because the village health centres do not provide us ARVs - they are constantly out of drugs," said Bosco Opiro of Pabbo, a former IDP camp in Amuru District. Opiro said his village of Lalem, also in Amuru, had no health centre; he and other HIV-positive people in the camp have chosen to remain in Pabbo and continue to collect their ARVs from the health centre in town rather than go back to Lalem.

KAKAMEGA - HIV could lose its "special status" in Kenya's health system if a new pilot programme integrating HIV care and public healthcare proves successful. Traditionally, public hospitals in Kenya have a "comprehensive care clinic" (CCC) dedicated to people living with HIV; under the new system, these would no longer exist. For more than six months, the Ministry of Health and its partners have been piloting the move in Western Province; senior government officials say it will not reduce the focus on HIV, but will ease pressure on an already overburdened and understaffed health system. "Integrating HIV treatment with other outpatient services doesn't mean it has become less important; it only means maximizing on space and reducing the burden on healthcare personnel and to help increase focus on other equally important diseases like malaria," said Ibrahim Mohamed, head of the National AIDS and sexually transmitted infections Control Programme, NASCOP.

Joshua Omoro likes the new system; he can sit easily with other patients as he waits to see the clinical officer on duty at the Tonguren Health Centre in Bungoma North District in Western Province. "I have come today to pick my [antiretroviral] medicine but nobody can know; people are just guessing what I might be suffering from just like I am also just guessing for other people," he said. "It puts you at ease... before when you went to a specific room, people just knew you had HIV."

The Obama administration Tuesday called on the U.N. Human Rights Council to fight discrimination against gays and lesbians around the world. "Human rights are the inalienable right of every person, no matter who they are or who they love," Eileen Chamberlain Donahoe, U.S. ambassador to the council in Geneva, said in a statement. "The U.S. government is firmly committed to supporting the right of lesbian, gay, bisexual and transgender individuals to lead productive and dignified lives, free from fear and violence." The council has condemned human rights violations based on sexual orientation or gender identity, including rape, torture and murder. "It is a really pressing issue globally that there continue to be killings on the basis of sexual orientation and persecution on that basis," said Suzanne Nossel, deputy assistant secretary of State for international organization affairs. "I think this will stimulate dialogue and increase recognition of the importance of the issue among governments."

This year marks a decade-long retreat in new HIV cases in San Francisco. Between 2001 and 2011 the city has witnessed a steady decline in new infections. Ten years ago the city estimated that more than 1,000 people would become infected with HIV, the large majority of whom were gay and bisexual men. Now San Francisco health researchers estimate there are 736 new HIV infections each year, according to the latest HIV Consensus Estimates. The number could actually be as low as 621 new HIV cases per year. Due to statistical uncertainty, researchers in the city's Department of Public Health Epidemiology Section advise that the "plausibility bounds" for new infections range from 534 cases at the low end to 977 cases at the upper end. The city's HIV incidence rate now stands at 0.09 percent, a 30.8 percent reduction in the rate since 2006. The city has also seen a 24.6 percent reduction in the number of cases over the last five years...

The majority of San Francisco's new HIV cases remains among men who have sex with men. It is estimated that 585 gay and bisexual men will become HIV-positive this year, the bulk of whom are likely to be in their 30s. Another 49 gay and bisexual men who use injection drugs are expected to contract HIV this year. In total, there are an estimated 15,873 gay and bisexual men living with HIV in the city. The HIV incidence rate among MSM who do not inject drugs stands at 1.27 percent based on a population of 59,809. The city's HIV prevalence among this population is at 22.7 percent. Health officials believe a variety of factors are leading to the continued downward trend. For one, while the city continues to see spikes in STDs, including syphilis, HIV-positive men account for a large portion of the cases. Combined with their continued adoption of sero-sorting, where HIV-positive men seek out other HIV-positive men as their sexual partners, the STD infections are not causing a spike in HIV cases. Another likely factor is the health department's policy of recommending HIV-positive people begin treatment early. It is believed to have led to less viral loads among at-risk populations, reducing the risk of HIV transmission between sex partners of sero-discordant HIV status. Researchers are currently studying the policy's impact to verify those claims.

Gilead Sciences Inc said on Wednesday that its experimental HIV drug elvitegravir proved as effective as a drug made by Merck & Co in a late-stage clinical trial. The trial showed that after 48 weeks of treatment, dosed once daily, elvitegravir was as effective as Merck's Isentress, which is dosed twice daily in combination with other antiretroviral drugs... Elvitegravir is designed to block the ability of the HIV virus to integrate into the genetic material of human cells. The drug is also part of a four-medicine HIV pill being developed by Gilead known as the "Quad." Last year a mid-stage trial showed the Quad works as well as Gilead's widely used Atripla three-drug tablet. Atripla combines Emtriva, Viread and Bristol-Myers Squibb Co's Sustiva... Results of the Phase III elvitegravir trial showed that after 48 weeks of treatment 59 percent of patients taking elvitegravir achieved target reductions in levels of HIV in the blood, known as viral load, compared with 57.8 percent of those who received Isentress, which is also known as raltegravir.

The paid advertisement in this issue of GA Voice correctly reminds us that "there is no magic pill" to prevent HIV infection. Unfortunately, the ad is part of a campaign to convince the FDA not to review, and Gilead Sciences not to submit, data to support approval of Truvada for HIV prevention. (Truvada is now available by prescription to treat HIV.) It is based on fear and speculation at a time when we need reason and research to guide us through scientific and policy issues raised by this new HIV prevention tool. In spite of 30 years of fighting HIV, there will be an estimated 2.7 million new HIV infections globally in 2011, with 56,000 of these in the US, a number that has remained stable across a decade. Gay and bisexual men, especially men of color, will bear a disproportionate burden of these infections, as will women of color.

But 2010 breathed new life into HIV prevention. The CAPRISA 004 study in 889 HIV-uninfected African women was the first to show that vaginal tenofovir gel (a microbicide) used before and after sex, and given with risk-reduction counseling and condoms, could decrease HIV infections in women by 39 percent. Months later, the iPrEx study of "pre-exposure prophylaxis" (PrEP) in 2,499 HIV-uninfected gay and bisexual men and transgender women showed that daily Truvada decreased HIV infections by 44 percent overall. All study volunteers received condoms, STD screening and treatment, and risk reduction counseling. However, drug levels showed that those who became infected were not taking drug, while up to 95 percent of persons with high drug levels were protected against HIV. Drug resistance was not associated with taking Truvada. Side effects of treatment were generally mild and infrequent.

When House Republicans took power in 1995 determined to cut spending in a battle that shut down the U.S. government, then-House Speaker Newt Gingrich was persuaded to spare the National Institutes of Health. Gingrich not only reconsidered his party's proposed cuts to the NIH budget after hearing concerns from business executives and Nobel laureates, he later supported a bipartisan move to double the research center's funding over five years. For Republicans who took control of the House this year, those concerns aren't resonating, and the NIH lacks a Republican champion. House Republicans are now pressing for a $1.6 billion, or 5.2 percent, spending cut to the center in Bethesda, Maryland, which includes the National Cancer Institute and other medical-research facilities.

Former Representative John Porter, a Republican who helped lead the 1995 move to boost NIH funding, and other critics say the cuts will hurt U.S. competitiveness and medical advances and underline the danger of across-the-board budget reductions. "I'd call it, frankly, mindless," said Porter, 75. Biomedical research "provides the kind of high-tech, high- paying jobs that we really want for our children and grandchildren. This is where we really make a difference in the lives of people all over the world." Porter, who oversaw the research center's funding while on the House Appropriations Committee and is now on the board of the NIH foundation, said he fears lawmakers don't understand the importance of the money in fighting disease or that much of it goes to institutions in their districts. Gingrich, 67, who's considering a 2012 presidential run, also objects to any NIH cuts. "We should be spending more, not less, on science," said his spokesman, Rick Tyler. In a Washington Post op-ed last month, Gingrich wrote that his party decided to be "smart rather than cheap" in making cuts. "We realized that cutting spending in areas that produce long-term savings was destructive to the goal of a sustainable balanced budget," he wrote.

When South African husband-and-wife research team professors Salim and Quarraisha Abdool Karim began to study ways in which women could protect themselves against HIV, money was the last thought on their minds. But now, months after their microbicide gel, tenofovir, was hailed as the "best Aids-prevention news in years", money is standing in their way.

Salim Karim, of the Centre for the Aids Programme of Research in SA, said the vaginal gel, which could prevent more than 800000 Aids-related deaths, might only appear on shelves by as late as 2014 because further studies to confirm its efficacy are being delayed by a lack of funds. After the initial findings of studies using tenofovir were presented to the International Aids Conference in Vienna, UNAIDS, the UN programme on HIV/Aids, called for a second study - to confirm the protective effect of the gel. "The Voice trial began this year. The results are expected to be out in 2013. While the confirmatory study is under way, we thought about the fastest way to put the gel in the hands of women, and we discovered that we could license it and get the gel registered with regulatory bodies, but for that we would need to have two confirmatory studies," Karim said. The Voice study is funded by the US National Institute of Health, but funding for the second confirmatory study has not been secured. Karim said at least $42-million would be needed for the research. "The lack of resources is pushing back the introduction of the gel to women around the world," he said.

The U.S. medical system is ill-prepared to cope with the number of Americans now infected with HIV, a new report suggests. Specifically, too few health care providers are adequately trained and experienced in providing the care these patients need, the report authors indicate. The observation is outlined in the third and final report of a series focused on the state of HIV health care in the United States that was put together by the Institute of Medicine (IOM), an independent, nonprofit organization.

"There will be numerous challenges as the nation begins implementing the [Obama administration's] new National HIV/AIDS Strategy," Paul Cleary, dean of the Yale School of Public Health in New Haven, Conn., said in a news release from the National Academy of Sciences. Cleary, chair of the committee that wrote the series, said that the reports set out to articulate "many practical suggestions from the research literature and experts about how to address and overcome the obstacles to a more effective and efficient HIV/AIDS strategy." Given the widening gap between HIV-care supply and demand, the report emphasizes the need for health-care provider flexibility, in order to overcome the constraints under which many providers labor. For example, the report authors say that collaboration across facilities should be encouraged, in order to better allocate and share sparse resources among multiple providers. However, at times such task-sharing may run afoul of state regulations, which can limit the ability of providers to share caseload responsibilities.

A robust public debate is under way about the potential use of anti-HIV drugs to prevent HIV infection (also known as pre-exposure prophylaxis or PrEP). Our study, called iPrEx, provided the first conclusive evidence that the daily use of PrEP with the FDA-approved HIV treatment Truvada can significantly reduce HIV infection risk in gay, bisexual, and other men who have sex with men and transgender women, when delivered as part of a comprehensive package of prevention services, including condoms. The protection provided by PrEP and condoms together could have a substantial impact in reducing new HIV infections among MSM worldwide. Recently, a private health care provider has begun a paid advertising campaign urging the FDA not to even consider approving the use of PrEP--charging, among other things, that MSM will stop using condoms if PrEP is permitted. The pros and cons of PrEP use should be vigorously debated--but that debate should be based on facts, rather than the assumption that MSM will not act to protect themselves and others from infection.

The latest issue of Sexually Transmitted Infections is now available.

Prevalence of sexually transmitted co-infections in people living with HIV/AIDS: systematic review with implications for using HIV treatments for prevention
Kalichman SC, et al.

Variations in the epidemiology of primary, secondary and early latent syphilis, England and Wales: 1999 to 2008
Jebbari H, et al.

The incidence of syphilis, HIV and HCV and associated factors in a cohort of men who have sex with men in Nanjing, China
Hao C, et al.

Gonorrhoea positivity among women aged 15 -24 years in the USA, 2005 - 2007
Gorgos L, et al.

The influence of bacterial vaginosis on the response to Trichomonas vaginalis treatment among HIV-infected women
Gatski M, et al.

Loss of quality of life associated with genital warts: baseline analyses from a prospective study
Senecal M, et al.

Health-related quality of life in Indian patients with three viral sexually transmitted infections: herpes simplex virus-2, genital human papilloma virus and HIV
Raj R, et al.

Increased HIV testing and reduced undiagnosed infection among gay men in Scotland, 2005 - 8: support for the opt-out testing policy?
McDaid LM, et al.

Which Chinese men who have sex with men miss out on HIV testing?
Wei C, et al.

Short message service reminder intervention doubles sexually transmitted infection/HIV re-testing rates among men who have sex with men
Bourne C, et al.

Post-prostatic massage fluid/urine as an alternative to semen for studying male genitourinary HIV-1 shedding
Graham SM, et al.

Performance of the Focus HerpeSelect-2 enzyme immunoassay for the detection of herpes simplex virus type 2 antibodies in seven African countries
Mujugira A, et al.

Impact of HIV testing on sexual health communication in South Africa
Scott-Sheldon L, et al.

Behavioural sources of repeat Chlamydia trachomatis infections: importance of different sex partners
Niccolai LM, et al.

Condom use by female sex workers and their clients in Mexico: who decides and does it matter?
Borquez A, et al.

HIV-related sexual risk behaviour between 1996 and 2008, according to age, among men who have sex with men (Scotland)
Knussen C, et al.

A new test for human papillomavirus (HPV) is just as sensitive as the old one, but more specific for detecting cervical cancer, meaning that it has fewer false positive results, according to a paper in the February 2011 Journal of Clinical Microbiology. "This is important because reducing false positive results avoids unnecessary additional tests and follow-up, the associated health care costs, and distress to women," says first author Sam Ratnam, of the Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador. HPV infection, he explains, is highly prevalent, but "only a small fraction of the infected are at risk of developing HPV-associated cancers." The investigators report that the new test, called the Aptima HPV test, detected 96.3 percent of women with high-grade cervical intraepithelial neoplasia or worse (CIN 2+) compared to 94.3 percent for the old test, the Hybrid Capture 2 DNA test (HC2), among 1418 women studied. But Aptima has far fewer false positives than HC2.... While HPV is the single most common sexually transmitted virus, its spread is increasing due to rising oral sex among young people, according the Oral Cancer Foundation.... While the role of HPV is most recognized in cervical cancer, it is also associated with anal and penile cancers, and cancers of the vagina and vulva. The test could detect HPV infections that have begun to progress towards these other HPV-associated cancers, says Ratnam. "The use of a more accurate test such as the Aptima test should improve the efficiency and cost-effectiveness of cervical cancer screening around the world, and should help prevent cervical cancer," says Ratnam.

Reference:
Ratnam S, Coutlee F, Fontaine D, Bentley J, et al. Aptima HPV E6/E7 mRNA test is as sensitive as Hybrid Capture 2 Assay but more specific at detecting cervical precancer and cancer. Journal of Clinical Microbiology, 2010; 49 (2): 557 DOI: 10.1128/JCM.02147-10

Over half of middle-aged HIV-positive patients in a large French cohort had poor lower-limb strength, French investigators report in the online edition of AIDS. They warn that this could mean the patients have a higher risk of falls and recommend that assessments of lower-limb strength should be carried out as part of routine HIV care. Problems with balance and a deterioration of muscle strength in the lower limbs (locomotor performance) are associated with ageing. Many patients with HIV are now living into older age, and the diseases of ageing are an increasingly important cause of illness and death in these individuals. Research conducted in 2002 showed that up to 30% of HIV-positive individuals had problems with muscle strength or balance... "Given the high frequency of poor [five-times sit-to-stand] performance...we recommend to perform [this] test in standard care," write the authors, who conclude with a call for longitudinal studies "to asses the evolution of locomotor performance and the incidence of falls and their impact on fractures in the HIV-infected population."

Reference
Richert L et al. High frequency of poor locomotor performance in HIV-infected patients. AIDS 25, (online edition), doi: 10. 1097/QAD.0bo13e3283455dff, 2011.

European research published in the February 28th edition of The Lancet shows the importance of considering the results of tests for transmitted resistance when selecting a patient's first combination of antiretroviral drugs. Individuals treated with a regimen which was not completely active were three times more likely to experience virologic failure during the first year of treatment than individuals with no resistance or those who had resistance but were treated with therapies to which the strain of HIV they had was fully susceptible. There was also some evidence that baseline resistance impaired immune recovery. "Transmitted drug resistance was associated with virological failure in patients who received at least one drug to which the virus had lost susceptibility," write the investigators, who say their findings underscore "the need for at least three fully-active antiretroviral drugs to optimise virological response to a first-line regimen."

In Europe, use of antiretroviral therapy has dramatically improved the prognosis of many patients with HIV. However, expanded use of HIV treatment has been accompanied by an increase in the transmission of drug-resistant HIV. Approximately 10% of all new infections in Europe involve a strain of virus that is resistant to at least one antiretroviral drug. Resistance is the major reason why anti-HIV drugs cannot control viral load. European and British guidelines recommend that all patients should be tested for drug resistance soon after their diagnosis with HIV and again before they start antiretroviral therapy. First-line HIV therapy should take into account the results of this surveillance. However, there is uncertainty about the impact of transmitted resistance on responses to first-line HIV treatment. This is especially the case if a patient with resistance takes a fully active combination of drugs.

Reference
Wittkop L et al. Effect of transmitted drug resistance on virological and immunological response to initial combination antiretroviral therapy for HIV (EuroCoord-CHAIN joint project): a European multicohort study. The Lancet Infectious Diseases, early online publication, 28 February 2011.

A major milestone in microfluidics could soon lead to stand-alone, self-powered chips that can diagnose diseases within minutes. The device, developed by an international team of researchers from the University of California, Berkeley, Dublin City University in Ireland and Universidad de Valparaiso Chile, is able to process whole blood samples without the use of external tubing and extra components. The researchers have dubbed the device SIMBAS, which stands for Self-powered Integrated Microfluidic Blood Analysis System. SIMBAS appeared as the cover story March 7 in the peer-reviewed journal Lab on a Chip.

"The dream of a true lab-on-a-chip has been around for a while, but most systems developed thus far have not been truly autonomous," said Ivan Dimov, UC Berkeley post-doctoral researcher in bioengineering and co-lead author of the study. "By the time you add tubing and sample prep setup components required to make previous chips function, they lose their characteristic of being small, portable and cheap. In our device, there are no external connections or tubing required, so this can truly become a point-of-care system." Dimov works in the lab of the study's principal investigator, Luke Lee, UC Berkeley professor of bioengineering and co-director of the Berkeley Sensor and Actuator Center. "This is a very important development for global healthcare diagnostics," said Lee. "Field workers would be able to use this device to detect diseases such as HIV or tuberculosis in a matter of minutes. The fact that we reduced the complexity of the biochip and used plastic components makes it much easier to manufacture in high volume at low cost. Our goal is to address global health care needs with diagnostic devices that are functional, cheap and truly portable."

Journal Reference:
Dimov IK, Basabe-Desmonts L, Garcia-Cordero JL, Ross BM, et al. Stand-alone self-powered integrated microfluidic blood analysis system (SIMBAS). Lab on a Chip, 2011; 11 (5): 845 DOI: 10.1039/C0LC00403K

Abstract
Over-the-counter personal lubricants are used frequently during vaginal and anal intercourse, but they have not been extensively tested for biological effects that might influence HIV transmission. We evaluated the in vitro toxicity anti-HIV-1 activity and osmolality of popular lubricants. A total of 41 lubricants were examined and compared to Gynol II and Carraguard as positive and negative controls for toxicity, respectively. Cytotoxicity was assessed using the XTT assay. The MAGI assay with R5 and X4 HIV-1 laboratory strains was used to evaluate antiviral activity. The effect of the lubricants on differentiated Caco-2 cell monolayers (transepithelial electrical resistance, TEER) was also measured. None of the lubricants tested showed significant activity against HIV-1. Surprisingly, four of them, Astroglide Liquid, Astroglide Warming Liquid, Astroglide Glycerin & Paraben-Free Liquid, and Astroglide Silken Secret, significantly enhanced HIV-1 replication (p < 0.0001). A common ingredient in three of these preparations is polyquaternium-15. In vitro testing of a chemically related compound (MADQUAT) confirmed that this similarly augmented HIV-1 replication. Most of the lubricants were found to be hyperosmolar and the TEER value dropped approximately 60% 2 h after exposure to all lubricants tested. Cells treated with Carraguard, saline, and cell controls maintained about 100% initial TEER value after 2-6 h. We have identified four lubricants that significantly increase HIV-1 replication in vitro. In addition, the epithelial damage caused by these and many other lubricants may have implications for enhancing HIV transmission in vivo. These data emphasize the importance of performing more rigorous safety testing on these products.

Abstract
Large-scale internal migration in China may be an important mechanism for the spread of HIV/sexually transmitted infections (STIs) because of the risk behaviours of migrants. We conducted a self-administered survey among 724 employees of a high-end entertainment centre in Kunshan, Jiangsu Province, China. Using logistic regression, we examined the association of hometown of origin (Kunshan city, elsewhere in Jiangsu Province, or another province in China) and consecutive years living in Kunshan with measures of HIV/STI risk behaviour. We found that increased time living in Kunshan was associated with lower odds of using condoms as contraception [odds ratio (OR) = 0.78, 95% confidence interval (CI): 0.64-0.95] and consistent condom use with a casual partner (OR = 0.66, 95% CI: 0.47-0.93), after controlling for gender, marital status age and income. The odds of having had an STI were significantly lower for Kunshan natives than those originally from outside provinces (OR = 0.25, 95% CI: 0.07-0.96), but increasing years living in Kunshan was not related to lower risk for an STI. Our findings do not support the hypothesis that migrants living far from home participate in higher risk behaviour than locals. Findings suggest that adaptation to local culture over time may increase HIV/STI risk behaviours, a troublesome finding.

Abstract
BACKGROUND The Caribbean has the highest prevalence rates of HIV/AIDS outside sub-Saharan Africa, and a broad literature suggests an ecological association between tourism areas and sexual vulnerability. Tourism employees have been shown to engage in high rates of sexual risk behaviours. Nevertheless, no large-scale or sustained HIV prevention interventions have been conducted within the tourism industry. Policy barriers and resources are under-studied.

METHODS In order to identify the policy barriers and resources for HIV prevention in the tourism sector, our research used a participatory approach involving a multisectoral coalition of representatives from the tourism industry, government, public health and civil society in the Dominican Republic. We conducted 39 in-depth semi-structured interviews with policy makers throughout the country focusing on: prior experiences with HIV prevention policies and programmes in the tourism sector; barriers and resources for such policies and programmes; and future priorities and recommendations.

RESULTS Findings suggest perceptions among policy makers of barriers related to the mobile nature of tourism employees; the lack of centralized funding; fear of the 'image problem' associated with HIV; and the lack of multisectoral policy dialogue and collaboration. Nevertheless, prior short-term experiences and changing attitudes among some private sector tourism representatives suggest emerging opportunities for policy change.

CONCLUSION: We argue that the time is ripe for dialogue across the public-private divide in order to develop regulatory mechanisms, joint responsibilities and centralized funding sources to ensure a sustainable response to the HIV-tourism linkage. Policy priorities should focus on incorporating HIV prevention as a component of occupational health; reinforcing workers' health care rights as guaranteed by existing law; using private sector tourism representatives who support HIV prevention as positive role models for national campaigns; and disseminating a notion of 'investment' in safer tourism environments as a means to positively influence tourist demand.

Abstract
Identification of immunogens capable of eliciting broadly neutralizing antibody (NAb) responses against HIV-1 is a major goal towards the development of an AIDS vaccine. Despite significant progress in understanding the structural features of the HIV-1 envelope glycoprotein (Env) and the discovery of multiple broadly neutralizing monoclonal antibodies with defined antigenic structures, the design of optimal Env immunogens to elicit broad NAb remains a major challenge. As the structural determinants of Env immunogenicity remain unclear, we assessed two closely-related Env antigens isolated from the same HIV-1 infected patient with different phenotypic features to identify what may result in a favorable immunogenic profile. One Env, B33, isolated from brain, was highly macrophage tropic with high CD4 affinity while the other, LN40, isolated from the lymph nodes, was poorly macrophage tropic with low CD4 affinity. Using a DNA prime-protein boost approach, rabbits primed with LN40 Env antigen had a NAb response against heterologous primary isolates while B33 Env antigens were capable of eliciting NAb against only homologous and sensitive viral isolates. Further analysis revealed that the specificity of NAb elicited by LN40 antigen was mapped to limited residues within or flanking the CD4 binding site. Certain key structural determinants were identified that can differentiate primary Env immunogens based on their potential to elicit broader NAb. This progress will facilitate the rational design of effective HIV-1 vaccine formulations with optimal Env antigens.

Abstract
BACKGROUND: In 2003, a phase III placebo-controlled trial (VAX003) was completed in Bangkok, Thailand. Of the 2,546 individuals enrolled in the trial based on high risk for infection through injection drug use (IDU), we obtained clinical samples and HIV-1 sequence data (envelope glycoprotein gene gp120) from 215 individuals who became infected during the trial. Here, we used these data in combination with other publicly available gp120 sequences to perform a molecular surveillance and phylodynamic analysis of HIV-1 in Thailand.

METHODOLOGY AND FINDINGS: Phylogenetic and population genetic estimators were used to assess HIV-1 gp120 diversity as a function of vaccination treatment, viral load (VL) and CD4+ counts, to identify transmission clusters and to investigate the timescale and demographics of HIV-1 in Thailand. Three HIV-1 subtypes were identified: CRF01_AE (85% of the infections), subtype B (13%) and CRF15_AE (2%). The Bangkok IDU cohort showed more gp120 diversity than other Asian IDU cohorts and similar diversity to that observed in sexually infected individuals. Moreover, significant differences (P<0.02) in genetic diversity were observed in CRF01_AE IDU with different VL and CD4+ counts. No phylogenetic structure was detected regarding any of the epidemiological and clinical factors tested, although high proportions (35% to 50%) of early infections fell into clusters, which suggests that transmission chains associated with acute infection play a key role on HIV-1 spread among IDU. CRF01_AE was estimated to have emerged in Thailand in 1984.5 (1983-1986), 3-6 years before the first recognition of symptomatic patients (1989). The relative genetic diversity of the HIV-1 population has remained high despite decreasing prevalence rates since the mid 1990s.

CONCLUSIONS: Our study and recent epidemiological reports indicate that HIV-1 is still a major threat in Thailand and suggest that HIV awareness and prevention needs to be strengthened to avoid AIDS resurgence.

Abstract
We describe lessons learned from a national HIV prevention research program grounded in community-based participatory research, the Men of Asia Testing for HIV (MATH) Study, which targeted self-identified Asian/Pacific Islander men in the United States who have sex with men. We discuss the genesis of and impetus for the study and then describe its various facets, including accomplishments, challenges, and unanticipated consequences. We conclude with a discussion about the real-world practice of community-based participatory research with respect to the MATH Study in particular and similar research in general.

Abstract
BACKGROUND: Characterization of viruses in HIV-1 transmission pairs will help identify biological determinants of infectiousness and evaluate candidate interventions to reduce transmission. Although HIV-1 sequencing is frequently used to substantiate linkage between newly HIV-1 infected individuals and their sexual partners in epidemiologic and forensic studies, viral sequencing is seldom applied in HIV-1 prevention trials. The Partners in Prevention HSV/HIV Transmission Study (ClinicalTrials.gov #NCT00194519) was a prospective randomized placebo-controlled trial that enrolled serodiscordant heterosexual couples to determine the efficacy of genital herpes suppression in reducing HIV-1 transmission; as part of the study analysis, HIV-1 sequences were examined for genetic linkage between seroconverters and their enrolled partners.

METHODOLOGY/PRINCIPAL FINDINGS: We obtained partial consensus HIV-1 env and gag sequences from blood plasma for 151 transmission pairs and performed deep sequencing of env in some cases. We analyzed sequences with phylogenetic techniques and developed a Bayesian algorithm to evaluate the probability of linkage. For linkage, we required monophyletic clustering between enrolled partners' sequences and a Bayesian posterior probability of greater than 50%. Adjudicators classified each seroconversion, finding 108 (71.5%) linked, 40 (26.5%) unlinked, and 3 (2.0%) indeterminate transmissions, with linkage determined by consensus env sequencing in 91 (84%). Male seroconverters had a higher frequency of unlinked transmissions than female seroconverters. The likelihood of transmission from the enrolled partner was related to time on study, with increasing numbers of unlinked transmissions occurring after longer observation periods. Finally, baseline viral load was found to be significantly higher among linked transmitters.

CONCLUSIONS/SIGNIFICANCE: In this first use of HIV-1 sequencing to establish endpoints in a large clinical trial, more than one-fourth of transmissions were unlinked to the enrolled partner, illustrating the relevance of these methods in the design of future HIV-1 prevention trials in serodiscordant couples. A hierarchy of sequencing techniques, analysis methods, and expert adjudication contributed to the linkage determination process.

The Anova Health Institute, with support from PEPFAR, will be conducting a regional symposium on HIV among MSM, with an emphasis on prevention, treatment and care, over the period 23 - 25 May 2011, at the Vineyard Hotel in Cape Town. The symposium is aimed at focusing awareness on various developments related to HIV among MSM in an African context. The symposium will highlight recent significant developments in terms of research focusing on MSM, including both bio-medical and psychosocial components of prevention, and highlight the growing experience in providing MSM focused HIV treatment and care in South Africa. The conference audience includes researchers, service providers, health service managers and advocates.

16th International Conference on AIDS and STIs in Africa (ICASA), theme "Own, Scale Up and Sustain" Addis Ababa, Ethiopia, 4-8 December 2011

Registration now open; early registration deadline with discounted rates through 31 May 2011. Abstract deadline is also 31 May.