Treatment News 2017

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New Recommendations Aim To Help Pregnant Women With HIV Make Informed Choices. 11/9/2017

Published by MEDICALEXPRESS

New recommendations on antiretroviral drugs for pregnant women living with HIV can help women make more informed choices about benefits and harms, say a panel of international experts in The BMJ today.

The recommendations, which take a patient's perspective rather than a public health perspective, differ from current guidelines, and are meant to support shared decision making between and their healthcare provider, say the authors. The new guidelines suggest that most women are likely to prefer older HIV medications rather than the ones that are most often currently prescribed.

Their advice is part of The BMJ's Rapid Recommendations initiative - to produce rapid and trustworthy guidance based on new evidence to help doctors make better decisions with their patients.

Every year about 1.4 million women living with HIV become pregnant. Most women take a combination of three to reduce the risk of transmission to their child or for personal health reasons. Recent trial evidence suggested that the most commonly used combinations might increase the risk of premature birth and neonatal death compared with other drug combinations.

So an international panel - made up of women living with HIV, specialist doctors, and general practitioners - carried out a detailed analysis of the evidence to make recommendations.

Their suggestions are based on data from two systematic reviews (published in BMJ Open) that looked at the benefits and harms of different drug combinations for pregnant women with HIV and the values and preferences of women considering antiretroviral therapy.

Evidence from these reviews led the panel to recommend older alternatives instead of the most widely used to help reduce the risk of and - which almost all women said they were extremely keen to avoid.

The panel acknowledge that the number of antiretroviral therapy options that women can choose from and can be prescribed varies considerably throughout the world - and that, in many settings, alternative drugs may not be available.

They also point out that their recommendations, like all BMJ Rapid Recommendations, take a patient centred perspective. Whereas guidelines that take a public health perspective, such as the WHO guideline, need to consider resource use and might make different recommendations based on the same evidence.

And they recognise the operational challenges that alternative treatment options may introduce, particularly in low resource settings.

In conclusion, they say there is a lack of reliable trial data on the safety and efficacy of most commonly used in pregnant women living with HIV.

They call for further research to inform treatment options, as well as efforts to overcome operational challenges "so that availability of the right choice of combination is aligned with the best available for almost all pregnant women living with HIV."

In a linked opinion piece, Alice Welbourn, a researcher, trainer, writer and activist on gender and sexual and reproductive health and rights, says women's fundamental rights to informed choices about what happens to their bodies are often curiously contested; especially if they are pregnant or have HIV. Yet, informed choices about risks and benefits form a critical part of long-term prognosis.

As Founding Director of the Salamander Trust, and a woman living with HIV, she welcomes the positive response by the new WHO director-general to support more people-centred policy developments.

She urges WHO to "ensure 's rights to informed, voluntary, and confidential choice about if, when, and how to start treatment safely, which treatment to consider, and how long to take it."                                                                 

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Liver Fibrosis Speeds Up Around The Menopause in Women With HIV and HCV Co-Infection. 22/8/2017

Published by AIDSMAP

Menopause is associated with accelerated liver fibrosis in women with HIV and hepatitis C virus (HCV) co-infection, investigators from the United States report in the online edition of Clinical Infectious Diseases. The study showed that liver damage due to fibrosis – the build-up of scar tissue after cell death caused by HCV-related inflammation – begins to speed up as the menopause takes place.

The researchers say that the findings have important clinical significance, suggesting that peri- and post-menopausal women should be prioritised as candidates for HCV therapy using direct-acting antiviral agents (DAAs) to avoid further liver damage.

“We found that liver fibrosis rates…increased as women transitioned through menopause,” comment the authors. “Importantly, we employed a robust statistical approach to account for potential confounding effects of chronological aging, and evaluated reproductive stages by hormonal confirmation of ovarian reserve. Acceleration of hepatic fibrosis also began during peri-menopausal years, suggesting that women may be at increased risk of liver scarring earlier than suggested by prior data relying on self-reported menopausal age.”

Up to 15% of people with HIV in the United States have co-infection with HCV, at least three times the HCV infection rate seen in the general population. Untreated HIV infection is associated with accelerated HCV-related liver fibrosis. Sex is also a risk factor for fibrosis progression, with men having higher rates than women. This is thought to be because of the protective effects of oestrogen in women, and higher rates of fibrosis have been observed in post-menopausal women.

However, previous research exploring the impact of reproductive ageing on fibrosis progression has been limited by lack of adjustment for chronological ageing and an absence of longitudinal follow-up. Moreover, the relationship between oestrogen and fibrosis progression has not been assessed in HIV-positive women.

Investigators from the Women Interagency HIV Study (WIHS) designed a study involving 405 women with HIV/HCV co-infection who were pre-menopausal at baseline. Progression of menopause and liver fibrosis were monitored longitudinally. To enable the investigators to robustly assess the relationship between reproductive ageing and the progression of liver fibrosis, data were also collected on chronological age, race, alcohol use, metabolic syndrome, HCV viral load and HIV-related factors (CD4 cell count, use of antiretroviral therapy [ART], viral load).

Menopausal status was assessed using serial measures of anti-Müllerian hormone (AMH). The level of AMH indicates the reserve of eggs left in the ovaries. Pre-menopause was defined as the presence of detectable AMH; peri-menopause was defined as the period within five years of AMH becoming undetectable; post-menopause was more than five years after AMH loss.

Fibrosis was assessed using two measures: APRI and FIB-4.The APRI and FIB-4 scales use levels of liver enzymes and platelets to calculate the extent of liver damage.

Median age at baseline was 37 years, and average age at the onset of menopause was 49 years. The majority of women were Hispanic (58%). At the start of the study, 6% had fibrosis stage 3 or above, which increased during follow-up to 32% when assessed using FIB-4 and 20% using APRI. Only 6% of participants reported heavy alcohol use. Most were taking ART (88%), but only 23% received any kind of HCV therapy with just 2% treated with DAAs. Approximately a quarter of participants had a history of diabetes and 11% had ever been diagnosed with metabolic syndrome.

Median follow-up was 9.1 years, and a fifth of women took some form of hormone replacement therapy during this period.

After taking into account chronological age, the investigators found that fibrosis was accelerated during peri-menopause compared to pre-menopause using FIB-4 (0.12 units/year faster; 95% CI, 0.02-0.21; p = 0.001) and APRI (0.05- units/year after; 95% CI 0.002-0.09; p = 0.06). Faster fibrosis progression was also present post-menopause compared to pre-menopause, though the difference was short of statistical significance for both FIB-4 (p = 0.07) and APRI (p = 0.06).

After adjustment for other potential confounders including Hispanic ethnicity, ART use and alcohol consumption, peri-menopause continued to be associated with accelerated fibrosis (0.10 FIB-4 units/year after vs pre-menopause; 95% CI, 0.008-0.20; p = 0.034).

“The current study represents an important advance in our understanding of the effects of reproductive ageing on liver fibrosis by highlighting the accelerated fibrosis that begins as early as pre-menopausal years,” comment the researchers. “Using AMH as a gold standard measurement of ovarian reserve we were able to evaluate each woman’s fibrosis rate as she transitioned across reproductive stage.”

The authors conclude that fibrosis progression in women with HIV/HCV co-infection accelerates with reproductive age, independent of chronological age. “Accelerated fibrosis began in peri-menopausal years, highlighting a previously unrecognized group of women at increased risk of progressive fibrosis and associated complications,” they note. “Similar analyses using serial measures of fibrosis should be conducted in non-HCV related liver diseases, including women without HIV infection, given potential implications of ovarian reserve on fibrosis progression in women with a broad spectrum of liver diseases.”

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No Evidence Of Reduced Efficacy Or Increased Side-Effects When Patients Switch To Generic Drugs, Comparison Study Finds. 24/8/2017

Published by AIDSMAP

An analysis of 440 people switched to generic antiretroviral drugs at an Italian clinic and a matched cohort of patients who remained on their branded medication has found no evidence of generic drugs being less effective or causing more side-effects, Nicola Gianotti and colleagues report in an article recently published in PLOS ONE.

In many high-income countries, health services are under increasing financial pressures. At the same time, the patents on several antiretroviral drugs have expired and cheaper, generic versions of the same drugs have been made available. Doctors and pharmacists are expected to use generic drugs when possible as they generally work as well as branded drugs, and the money saved can pay for other treatments and services. (For more information on generic medicines, click here).

Nonetheless, some people question the quality and efficacy of generic drugs. Generic manufacturers must prove that their products have the same pharmacokinetic properties as the original formulation, with comparable drug levels of the active ingredients, but are not required to run clinical trials with head-to-head comparisons of generic and branded medicines. Furthermore, small differences in a medicine’s non-active ingredients and manufacturing processes could potentially have an impact for a minority of patients.

Previous studies on generic antiretrovirals have all been conducted in low or middle-income countries. Moreover, only one previous study has compared outcomes between patients prescribed branded and generic drugs – in an observational cohort of almost 15,000 Zambian patients beginning HIV treatment, half received branded zidovudine and half generic zidovudine. There were no differences in mortality, weight gain or CD4 response, but virological response was not assessed.

Switching to generics in Italy

The study comes from a single clinic in Milan, Italy. Beginning in September 2014, all patients who were stable on branded lamivudine (Epivir), zidovudine/lamivudine (Combivir) or efavirenz (Sustiva) were switched to a generic version of the same drug.

The researchers compared outcomes for this group with a matched cohort of patients at the same clinic who did not switch drugs. It is important to note that this control group is not made up of patients taking the same drugs (lamivudine, zidovudine/lamivudine or efavirenz). Those in the control group were taking other antiretrovirals which were not available in generic formulations. However, the control group was well matched in other respects, including demographics and previous experience of treatment.

Amongst the 440 switchers and 440 non-switchers, three-quarters were men, most were in their late forties or their fifties, and the median time since HIV diagnosis was 19 years. All participants had an undetectable viral load. Their median CD4 cell count was around 700, their median lowest ever CD4 cell count was a little over 200 and over a quarter had antibodies to hepatitis C.

As noted, there were differences in terms of drugs taken. Whereas 40% of switchers were taking protease inhibitor-based dual therapy, this was the case for just 8% of non-switchers. Only 60% of switchers were taking triple therapy, compared to 92% of non-switchers.

Results

The researchers assessed outcomes after an average of 15 months of follow-up. Key outcomes were virological failure and treatment discontinuation.

Concerning virological failure (confirmed viral load over 50 copies/ml), there were four cases in switchers and ten in non-switchers. Virological failure was therefore less common in those taking generics and the difference was statistically significant.

In order to look at virological outcomes in more detail, the researchers also looked at viral blips (single viral load measures over 50 copies/ml) and time spent with residual viremia (a viral load below 50 copies/ml that remained detectable on the Abbot Real-Time PCR; this has been associated with a higher risk of subsequent virological failure). There were no statistically significant differences – viral blips occurred in 32 switchers and 33 non-switchers; time spent with residual viremia was 29% and 30% respectively.

Treatment discontinuation (any change in drug regimen) occurred in 118 (27%) of switchers and 128 (29%) of non-switchers. In both groups, the key reasons for changing drugs were side-effects, simplifying treatment and drug-drug interactions. The rate of treatment discontinuation is high but comparable to other cohorts of Italian people living with HIV.

Because of the important differences in drug regimen between the two groups, the researchers also conducted a sensitivity analysis which only included patients treated with standard triple therapy. Virological failure was less common in those switching to generics. Treatment discontinuation also appeared to be less common, but the difference was not statistically significant. 

Conclusions

“In this observational study we compared patients switched to generic antiretrovirals with a matched population who continued taking branded drugs and we did not find evidence of reduced efficacy or increased toxicity related to switch from branded to generic antiretroviral drugs,” the authors say. Moreover, their findings on virological failure would suggest that “the virological potency of these generic formulations is at least as high as that of the patent drugs”.

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Adult antiretroviral therapy guidelines 2017. 7/2017

Published by SAHIVSOC

These guidelines are intended as an update to those published in the Southern African Journal of HIV Medicine in 2014 and the update on when to initiate antiretroviral therapy in 2015. Since the release of the previous guidelines, the scale-up of antiretroviral therapy (ART) in southern Africa has continued. New antiretroviral drugs have become available with improved efficacy, safety and robustness. The guidelines are intended for countries in the southern African region, which vary between lower and middle income.

You can access the resource here

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To Be Successful, Multi-Month Prescribing Needs Fine Tuning. 9/8/2017

Published by MEDICALBRIEF

Shifts to less frequent clinic visits and medication pick-ups to free up healthcare resources and make life easier for people living with HIV are being implemented successfully in some African countries, but still need fine tuning, several studies presented at the 9th International AIDS Society Conference on HIV Science (IAS 2017) show.

The studies looked at the practice of multi-month prescribing, by which clinics provide several months of antiretroviral drugs at one time to people living with HIV in their care, in order to reduce the need for monthly clinic visits to pick up refills of medication.

Frequent clinic visits can be difficult to manage, especially if the clinic is a long way from home, transport is unaffordable or working hours prevent attendance at the clinic.

Less frequent clinic visits have been associated with better retention in HIV care in a large study in Zambia, and in other southern African countries, and also have the potential to reduce clinic congestion and increase the number of people who can be started on antiretroviral therapy (ART) as countries move to “Test and Treat” guidelines recommending treatment for all people living with HIV.

The practice of multi-month prescribing is central to the concept of differentiated care, through which people with less complex medical needs can receive more care in the community in order to free up medical resources for people who are sicker, those starting treatment and those with viral rebound.

Multi-month prescribing will not be suitable for everyone. In Malawi, for example, multi-month prescribing is offered to adults who have been on ART for at least six months, who have a viral load below 1000 copies/ml and good adherence. People with opportunistic infections or tuberculosis are required to attend the clinic more frequently. These criteria are designed to ensure that people with more complex clinical needs, and those who have recently started treatment, are not lost to follow-up.

But how does multi-month prescribing work out in practice? A survey of 30 health care facilities in Malawi shows that although two-thirds of people who are eligible for multi-month prescribing are receiving their medication in this way, so too are 42% of people who are not eligible for multi-month prescribing.

The survey, presented by Margaret Prust of the Clinton Health Access Initiative, looked at 75,364 people receiving treatment at 30 clinics in 2016 – 86% of patients were eligible and, of these, 73% were receiving multi-month prescribing. However, 42% of those ineligible for multi-month prescribing were receiving it too – approximately 5% of all patients. More than three-quarters of ineligible patients shifted to multi-month prescribing had detectable viral load above 1000 copies/ml and 39% of ineligible patients had not been on ART long enough to qualify.

A survey of health care workers and interviews with clinic managers explored the reasons for providing multi-month prescribing to patients who were not eligible. A lack of knowledge of the criteria for shifting patients to multi-month prescribing was a major reason for failing to offer multi-month prescribing or offering it to the wrong patients, but ineligible patients were also being moved to multi-month prescribing to reduce clinic workload or if they asked for it. Prust said that a need to travel to work far away from the clinic often motivated these requests.

Further training and job aids are needed for health care workers to help them to distinguish which patients are eligible, the study investigators concluded; better alignment of electronic and paper records would also ensure that health care workers have up-to-date information about viral load results, for example.

Although multi-month prescribing has been restricted largely to adults in Malawi, Baylor International Paediatric AIDS Initiative has been offering multi-month prescribing for children and adolescents at health care facilities in six African countries. So far, just over 15,000 children have been moved to multi-month prescribing and viral load suppression remains high. Only 1.8% of patients switched to multi-month prescribing have been lost to follow-up.

The study looked at the clinical outcomes of children and adolescents shifted to multi-month prescribing in Botswana, Lesotho, Swaziland, Malawi, Uganda and Tanzania. Children and adolescents were eligible for multi-month prescribing if they were clinically stable and adherent to ART, after six to nine months of monthly prescription pick-ups.

On average, children and adolescents shifted to multi-month prescribing attended the clinic every 61 days, compared to a mean interval of 39 days between visits for those on monthly prescribing. Patients who shifted to multi-month prescribing tended to have better long-term outcomes, as one would expect in a group of patients selected for the intervention on the basis of good short-term outcomes.

But, said Professor Maria Kim of Baylor Children’s Foundation, the take-home message of the study was that children continued to do well after switching to multi-month prescribing. The study found no differences in loss to follow-up between different age groups switched to multi-month prescribing, nor between countries.

Another model of reducing clinic visits is to devolve medication pick-up to adherence clubs in the community. A member can be assigned the responsibility to visit the clinic every two to three months to pick up medication for the other members of the club, or a nurse can attend the club to deliver drugs and draw blood for viral load testing. Members attend the club for counselling and to pick up their medication.

Community adherence clubs developed by Médecins Sans Frontières (MSF) in South Africa have shown promising results in observational studies.

Results of a two-year randomised study comparing community and clinic-based adherence clubs were presented by Colleen Hanrahan of Johns Hopkins Bloomberg School of Public Health, Baltimore. The study was carried out at Witkoppen Clinic in Johannesburg, South Africa, where 775 adults were randomised to attend a clinic- or community-based adherence club every two months.

The primary outcome of the study was the proportion of people in each study arm referred back to standard clinic-based care. Patients were referred back to standard clinic-based care if they missed a club visit without ART pick-up within 5 days, had two consecutive late ART pick-ups, developed a comorbidity requiring closer monitoring, or had viral load rebound. Women who became pregnant during the study were also referred back to the clinic.

The study population was approximately two-thirds female (65%) and had a high median CD4 cell count (506 cells/mm3). Participants were followed for two years. After two years, 57% of people in the clinic-based clubs were retained in care and had suppressed viral load compared to 47% in the community-based clubs (p = 0.003). The most common reasons for loss from club care and referral back to the clinic were missing a club visit and failing to pick up medication, and viral load rebound.

Abstract 1
Background: The provision of three-month antiretroviral (ARV) refills, or multi-month scripting (MMS), for stable HIV patients on antiretroviral therapy (ART) can increase service efficiency and decrease congestion. Since 2008, Malawi has offered MMS to patients that are 18 years or older, have been on ART at least six months, are on first-line ART, have no adverse drug reactions or opportunistic infections, have a viral load less than 1000 copies/mL, and have good adherence according to pill counts. We assessed the extent to which patients are accurately differentiated as eligible or ineligible for MMS and explored potential causes of inaccurate patient differentiation.
Methods: Data were collected from 30 purposefully selected ART facilities in 2016. Participation and eligibility for MMS were determined based on 75,364 patient clinical records, which were analyzed using Stata version 13. Results were weighted and clustered by facility. The reasons for inaccurate patient differentiation were explored using structured surveys with 136 health workers and 32 qualitative interviews with clinic management. Interviews were audio recorded, transcribed and thematically coded.
Results: A majority of patients (86.4%, 95% confidence interval [CI] 84.0-88.6) were eligible and 68.7% of patients (95% CI 62.5-74.6) were receiving MMS. Among patients eligible for MMS, 72.9% (95% CI 66.3-78.6) received MMS. However, 42.3% (95% CI 33.1-52.0) of ineligible patients (amounting to 5.7% of all patients) also received MMS. Results were similar based on sensitivity analyses using different eligibility criteria scenarios, but variation in the application of criteria existed across facilities. Among ineligible patients receiving MMS, 77% had viral load greater than 1000 copies/mL, and 39% had been on ART less than six months. Inaccurate patient differentiation was suggested to result from lack of health worker knowledge of the criteria for MMS, patient requests, health worker attempts to reduce workload, and perceived challenges with low stocks of medications.
Conclusions: MMS is being widely implemented in Malawi, but patient differentiation in many facilities is not happening according to the agreed upon definition of eligibility. Simplification of guidance, improvements in health worker mentorship, patient counseling, and alignment of patient record forms against eligibility criteria would improve patient differentiation in Malawi.

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New ARV Drug a Game-Changer for HIV​ Patients. 27/7/2017

Published by IOL

The much-anticipated antiretroviral (ARV) dolutegravir will be introduced as the first-line treatment for the HIV infected in South Africa as early as April, Health Department deputy director-general Dr Yogan Pillay said at the 9th International Aids Society (IAS) conference on HIV Science in Paris this week.

A dolutegravir-based regimen will be a “game-changer” for South Africa and people living with HIV because it has fewer side-effects and is cheaper than existing treatments, according to Professor Francois Venter from the Wits Reproductive Health and HIV Institute. 

Initially planned to enter the South African market in October next year, Pillay said that the timing would depend on when suppliers register the fixed-dose-combination (FDC) version with the Medicines Control Council. 

“During this conference, I’ve been meeting all the suppliers to find out when they will register. We think that definitely two, most likely three, will register this year and if they register we can start earlier,” he said. 

ARV therapy requires taking three drugs a day, every day, for life, but treatment is made easier when all the drugs are combined into one pill – an FDC. 

He said that current treatment based on the drug efavirenz had side-effects that can be severe and make the medication difficult to take for patients. These included mental health and liver problems. 

Dolutegravir’s side-effects are milder and much less common and could make taking treatment for life much easier. 

According to a January paper published in the South African Medical Journal, a dolutegravir-based regimen could translate into initial cost-savings of 20% of the country’s annual ARV budget. When volumes are met, when the majority of patients have been switched to the regimen, cost savings could reach 50%. 

Venter said this was largely due to the price of the raw materials used to manufacture the drug. The cost savings are highly significant as South Africa runs the largest ARV programme in the world and spends roughly R10 billion a year on procuring the medicines for local patients. Dolutegravir could also solve the country’s ARV-resistance problem, said Venter. 

He said reports indicated that at least 10% of patients on treatment had developed resistance to first-line ARVs. 

HIV-drug resistance occurs when individuals do not take their medicines as prescribed. 

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HIV treatment: Strategies to Reach The Next 10 Million Patients. 27/7/2017

Published by DEVEX

A man takes antiretroviral therapy medication in Malaysia. 

The last time the International AIDS Society Conference on HIV Science met in 2003, fewer than 2 million people globally were on HIV treatment. As the event returned to Paris this week, UNAIDS reported 19.5 million people are now taking antiretroviral therapy, or ART.

The numbers put the world on track to reach 30 million people on treatment by 2030 — a critical benchmark to actually end the AIDS epidemic. Life for patients on treatment has also improved; if they stick to the daily treatment, most can be expected to live a near-normal lifespan.

Yet campaigners know that reaching the next 10 million people with treatment will be harder in some ways. These patients are among the most difficult to reach: People living in conflict areas, stigmatized and criminalized populations — like men who have sex with men and sex workers — and young people, leery at the thought of taking HIV medication every day for the rest of their lives.

“We are seeing major progress in epidemics that are heterosexual in nature and we are seeing this mainly happening in adults. It's unquestionably a huge success,” Luiz Loures, the deputy executive director of the Joint United Nations Programme on HIV/AIDS, told Devex. “But there are several epidemics going on and some of them, they are the same that we saw in the pretreatment era.”

Those split results helped center discussions at this week’s IAS meeting around how to make it easier for patients to access and stay on treatment — key improvements that could help in reaching the most vulnerable. HIV advocates hope that a combination of scientific breakthroughs and experience-informed social outreach can bridge the final gaps in treatment.

Researchers and programmers are specifically thinking about strategies to make it easier for patients in some of the most difficult settings to start and maintain ARTs, as well as to reduce the number of times patients must travel to health clinics to pick up antiretroviral, ARV, drugs. Potential scientific breakthroughs in long-lasting, injectable ARVs may also mean HIV patients would no longer be looking at a lifetime of daily pills, often a deterrent or obstacle for care.

Longer lasting treatment

Among the highest-profile findings presented at the IAS conference were promising results, based on nearly two years of data, on the viability of an injectable HIV treatment. Researchers are testing both four- and eight-week regimens.

The research has drawn great interest from HIV patients and treatment programs looking for alternatives to the daily regimen of pills, especially for young people and adolescents. A shot every four or eight weeks could reduce the risk of skipped doses and help overcome the stigma that comes with keeping large quantities of ARVs on hand.

“It's been surprising to me in the patients at our site who are on this study how much they appreciate not having to take pills,” said Dr. Joseph Eron, one of the lead researchers on the trial. “That's something I didn't really calculate.”

HIV experts are only beginning to consider the possibilities presented by long-lasting injectables. Although they would currently need to be administered by a health worker, the prospect of self-injecting treatment may not be far off. Such a shift could better safeguard patients’ privacy and reduce the time they need to spend accessing ART, both of which may encourage more people to start treatment. Now programmers are waiting for the science to catch up to their ideas.

In the current experimental regimen, “the treatment was very well tolerated,” Eron said. “Patient satisfaction was very high. The injectable regimen is moving on to phase three studies,” with expanded numbers of volunteers enrolled for a longer period.

Patients who were participating in the trial had already started treatment and achieved viral suppression, meaning that while the virus remains in the body, it is nearly impossible to detect. This drastically improves the health of the patient and makes it nearly impossible for him to pass the virus to someone else.

After 96 weeks of study, 87 percent of the patients who were receiving an injection every four weeks remained virally suppressed. That number climbed to 94 percent among people getting a shot every eight weeks. Researchers said they will have a better understanding of which method is most effective and why, after the next round of advanced trials. Yet they caution that despite the promise, injectable ART is far from widespread deployment.

Strategies in the field

With medical breakthroughs still several years from the market, researchers are also looking at innovative ways to deliver existing treatment options in complex situations.

One such example has unfolded in the Yambio region of South Sudan, where HIV prevalence is estimated at 7 percent and even basic health services are limited. Beginning in 2015, Médecins Sans Frontières introduced a roving, mobile service to begin rapid testing patients for HIV. MSF tested more than 13,000 people and had started 344 of the 442 who tested positive on treatment.

Then, toward the end of 2015 and the beginning of 2016, fighting in South Sudan’s civil conflict reached Yambio. The patients were at times cut off from reaching MSF, said Cecilia Ferreyra, an advisor on HIV and tuberculosis for MSF. “They couldn't reach us and we couldn't reach them.”

MSF teams stuffed bags with up to three months' worth of treatment for each patient and passed them off to community health workers, who managed to get them to the majority of patients. As fighting flared, patients did not have to choose between risking their lives to access refills or stopping treatment, which brings a possibility that the virus could rebound or they could develop drug resistance.

As the situation stabilized in early 2016, MSF officials started tracking down the HIV patients. Eight had died because of complications from the disease and more than 60 had disappeared, either because they had been killed or displaced to other regions. But the rest had been able to maintain their treatment through the months-long fighting.

Ferreyra said it was critical to continue working with communities like Yambio to deliver testing and treatment. As a member of a global interagency task team that focuses on providing services in conflict settings, she said MSF is pushing other organizations to introduce their own plans to help patients remain on treatment. South Sudan also brought home the lesson that “wherever you are, you need a contingency plan,” she said.

Continuous care has obvious benefits for the patients, but back up plans for high-risk environments could also help agencies feel more comfortable about expanding their services in these settings, she said.

Staying on track

Even as researchers look at ways to start more people on treatment, they are also collecting evidence on what strategies can encourage patients to stay on ART. IAS devoted several sessions to sharing research on efforts to simplify HIV services to reflect the needs of clients, a method known as differentiated care.

One of the more promising approaches has been to increase the number of ARVs a health worker can prescribe, which dramatically reduces the need for often time-consuming and expensive clinic visits. In 2016, the World Health Organization came out in favor of reduced visits for patients who are stable on ART.  

Those recommendations so far do not extend to children and adolescents — simply because there was not enough research on the subject. Dr. Maria Kim with the Baylor International Pediatric AIDS Initiative led one effort to try to shore up that knowledge.

Her team consulted the records of more than 18,000 HIV patients ranging in age from newborns to 19 year olds, who received multimonthly prescriptions. They found a 75 percent adherence rate and a nearly 79 percent rate of viral suppression.

Kim said the findings offer potential lessons to health workers and others doing drug delivery. “Children, if they are stable and have caregivers who are supportive and they're already adherent for six months, they're likely to do okay.”

The job now, experts said, is for researchers to keep boosting the evidence so that policymakers can translate tested ideas into action.

 

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Lesson from Mabele’s Death: Keep Taking Your ARVs. 25/7/2017

Published by HEALTHE

Iconic AIDS activist Prudence Mabele, who died two weeks ago, had either stopped taking her antiretroviral treatment or she had become immune to it.

At the time of her death, Mabele’s CD4 count was a miniscule 14, according to Sibongile Tshabalala, deputy general secretary of the Treatment Action Campaign (TAC).

A CD4 count is a measure of how strong a person’s immune system is. Healthy people have a CD4 count of at least 500, and doctors use this measure as well as viral load tests to see whether a person is responding to ARV treatment.

Meanwhile, TAC founder Zackie Achmat revealed over the weekend that Mabele “regularly joked that she interrupted her antiretroviral treatment”.

“Treatment holidays’ are dangerous and most probably were the cause of her premature death,” said Achmat.

Mabele’s partner for the past year, Lucinda van den Heever, said Mabele had “been to hospital more than once” recently.

‘Battling with her body’

“She had pneumonia. She was infected with TB… she was battling with her body,” said Van den Heever. “But she was fighting to live, she wanted to live.

“There was fear in her eyes, deep vulnerability. She pushed me away because she was terrified for me to see her like that. She found it difficult to let her armour down. She tried so hard and fought with everything she had.”

Since Mabele’s death, many people on long-term ARV treatment have spoken about how difficult it is to remain on treatment – particularly “second-line” ARVs. These second line drugs are for people who have developed resistance to first-line ARVs, and have numerous side effects.

For example, some ARVs, particularly protease inhibitors (PI), can cause diabetes, in part because the medicine interferes with the body’s absorption of glucose..

“The introduction of dolutegravir in late 2018, which doesn’t impact on glucose, will partly fix this,” says Professor Francois Venter from the Wits Reproductive Health and HIV Institute (WRHI). “We are also working on second line drugs that impact on glucose, to make them safer, which will hopefully become available in 2018 or 2019”.

“[Mabele’s] death was the failure of a health system,” said Tshabalala, lambasting the failure of governments to include treatment literacy and support for patients in their HIV plans

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Less Frequent Clinic Visits for HIV Care: Fine Tuning Needed. 24/7/2017

Published by AIDSMAP

Shifts to less frequent clinic visits and medication pick-ups to free up healthcare resources and make life easier for people living with HIV are being implemented successfully in some African countries, but still need fine tuning, several studies presented on Monday at the 9th International AIDS Society Conference on HIV Science (IAS 2017) show.

Frequent clinic visits can be difficult to manage, especially if the clinic is a long way from home, transport is unaffordable or working hours prevent attendance at the clinic.

The studies looked at the practice of multi-month prescribing, by which clinics provide several months of antiretroviral drugs at one time to people living with HIV in their care, in order to reduce the need for monthly clinic visits to pick up refills of medication. Frequent clinic visits can be difficult to manage, especially if the clinic is a long way from home, transport is unaffordable or working hours prevent attendance at the clinic.

Less frequent clinic visits have been associated with better retention in HIV care in a large study in Zambia, and in other southern African countries, and also have the potential to reduce clinic congestion and increase the number of people who can be started on antiretroviral therapy (ART) as countries move to 'Test and Treat' guidelines recommending treatment for all people living with HIV.

The practice of multi-month prescribing is central to the concept of differentiated care, through which people with less complex medical needs can receive more care in the community in order to free up medical resources for people who are sicker, those starting treatment and those with viral rebound.

Multi-month prescribing will not be suitable for everyone. In Malawi, for example, multi-month prescribing is offered to adults who have been on ART for at least six months, who have a viral load below 1000 copies/ml and good adherence. People with opportunistic infections or tuberculosis are required to attend the clinic more frequently. These criteria are designed to ensure that people with more complex clinical needs, and those who have recently started treatment, are not lost to follow-up.

Multi-month prescribing in practice: Malawi

But how does multi-month prescribing work out in practice? A survey of 30 health care facilities in Malawi shows that although two-thirds of people who are eligible for multi-month prescribing are receiving their medication in this way, so too are 42% of people who are not eligible for multi-month prescribing.

The survey, presented by Margaret Prust of the Clinton Health Access Initiative, looked at 75,364 people receiving treatment at 30 clinics in 2016. Eighty-six per cent of patients were eligible and, of these, 73% were receiving multi-month prescribing. However, 42% of those ineligible for multi-month prescribing were receiving it too – approximately 5% of all patients. More than three-quarters of ineligible patients shifted to multi-month prescribing had detectable viral load above 1000 copies/ml and 39% of ineligible patients had not been on ART long enough to qualify.

A survey of health care workers and interviews with clinic managers explored the reasons for providing multi-month prescribing to patients who were not eligible.

A lack of knowledge of the criteria for shifting patients to multi-month prescribing was a major reason for failing to offer multi-month prescribing or offering it to the wrong patients, but ineligible patients were also being moved to multi-month prescribing to reduce clinic workload or if they asked for it. Margaret Prust said that a need to travel to work far away from the clinic often motivated these requests.

Further training and job aids are needed for health care workers to help them to distinguish which patients are eligible, the study investigators concluded; better alignment of electronic and paper records would also ensure that health care workers have up-to-date information about viral load results, for example.

Multi-month prescribing for children and young people

Although multi-month prescribing has been restricted largely to adults in Malawi, Baylor International Pediatric AIDS Initiative has been offering multi-month prescribing for children and adolescents at health care facilities in six African countries. So far, just over 15,000 children have been moved to multi-month prescribing and viral load suppression remains high. Only 1.8% of patients switched to multi-month prescribing have been lost to follow-up.

The study looked at the clinical outcomes of children and adolescents shifted to multi-month prescribing in Botswana, Lesotho, Swaziland, Malawi, Uganda and Tanzania. Children and adolescents were eligible for multi-month prescribing if they were clinically stable and adherent to ART, after six to nine months of monthly prescription pick-ups.

On average, children and adolescents shifted to multi-month prescribing attended the clinic every 61 days, compared to a mean interval of 39 days between visits for those on monthly prescribing. Patients who shifted to multi-month prescribing tended to have better long-term outcomes, as one would expect in a group of patients selected for the intervention on the basis of good short-term outcomes.

But, said Professor Maria Kim of Baylor Children’s Foundation, the take-home message of the study was that children continued to do well after switching to multi-month prescribing. The study found no differences in loss to follow-up between different age groups switched to multi-month prescribing, nor between countries.

Community-based adherence clubs

Another model of reducing clinic visits is to devolve medication pick-up to adherence clubs in the community. A member can be assigned the responsibility to visit the clinic every two to three months to pick up medication for the other members of the club, or a nurse can attend the club to deliver drugs and draw blood for viral load testing. Members attend the club for counselling and to pick up their medication.

Community adherence clubs developed by Médecins Sans Frontières (MSF) in South Africa have shown promising results in observational studies.

Results of a two-year randomised study comparing community and clinic-based adherence clubs were presented by Colleen Hanrahan of Johns Hopkins Bloomberg School of Public Health, Baltimore. The study was carried out at Witkoppen Clinic in Johannesburg, South Africa, where 775 adults were randomised to attend a clinic- or community-based adherence club every two months.

The primary outcome of the study was the proportion of people in each study arm referred back to standard clinic-based care. Patients were referred back to standard clinic-based care if they missed a club visit without ART pick-up within 5 days, had two consecutive late ART pick-ups, developed a comorbidity requiring closer monitoring, or had viral load rebound. Women who became pregnant during the study were also referred back to the clinic.

The study population was approximately two-thirds female (65%) and had a high median CD4 cell count (506 cells/mm3). Participants were followed for two years. After two years, 57% of people in the clinic-based clubs were retained in care and had suppressed viral load compared to 47% in the community-based clubs (p = 0.003). The most common reasons for loss from club care and referral back to the clinic were missing a club visit and failing to pick up medication, and viral load rebound.

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WHO Urges Action Against HIV Drug Resistance Threat. 20/7/2017

Published by WHO

WHO alerts countries to the increasing trend of resistance to HIV drugs detailed in a report based on national surveys conducted in several countries. The Organization warns that this growing threat could undermine global progress in treating and preventing HIV infection if early and effective action is not taken.

The WHO HIV drug resistance report 2017 shows that in 6 of the 11 countries surveyed in Africa, Asia and Latin America, over 10% of people starting antiretroviral therapy had a strain of HIV that was resistant to some of the most widely used HIV medicines. Once the threshold of 10% has been reached, WHO recommends those countries urgently review their HIV treatment programmes.“Antimicrobial drug resistance is a growing challenge to global health and sustainable development,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “We need to proactively address the rising levels of resistance to HIV drugs if we are to achieve the global target of ending AIDS by 2030.”

HIV drug resistance develops when people do not adhere to a prescribed treatment plan, often because they do not have consistent access to quality HIV treatment and care. Individuals with HIV drug resistance will start to fail therapy and may also transmit drug-resistant viruses to others. The level of HIV in their blood will increase, unless they change to a different treatment regimen, which could be more expensive – and, in many countries, still harder to obtain.

Of the 36.7 million people living with HIV worldwide, 19.5 million people were accessing antiretroviral therapy in 2016. The majority of these people are doing well, with treatment proving highly effective in suppressing the HIV virus. But a growing number are experiencing the consequences of drug resistance.

WHO is therefore issuing new guidelines to help countries address HIV drug resistance. These recommend that countries monitor the quality of their treatment programmes and take action as soon as treatment failure is detected.

"We need to ensure that people who start treatment can stay on effective treatment, to prevent the emergence of HIV drug resistance," said Dr Gottfried Hirnschall, Director of WHO’s HIV Department and Global Hepatitis Programme. “When levels of HIV drug resistance become high we recommend that countries shift to an alternative first-line therapy for those who are starting treatment.”

Increasing HIV drug resistance trends could lead to more infections and deaths. Mathematical modelling shows an additional 135 000 deaths and 105 000 new infections could follow in the next five years if no action is taken, and HIV treatment costs could increase by an additional US$ 650 million during this time.

Tackling HIV drug resistance will require the active involvement of a broad range of partners. A new five-year Global Action Plan calls on all countries and partners to join efforts to prevent, monitor and respond to HIV drug resistance and to protect the ongoing progress towards the Sustainable Development Goal of ending the AIDS epidemic by 2030. In addition, WHO has developed new tools to help countries monitor HIV drug resistance, improve the quality of treatment programmes and transition to new HIV treatments, if needed.

The WHO HIV drug resistance report 2017 was co-authored by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Centers for Disease Control and Prevention, USA.

“This new report shows a worrying picture of increasing levels of HIV drug resistance and, if unchecked, it will be a major risk to program impact,” said Dr Marijke Wijnroks, Interim Executive Director of the Global Fund. “We strongly recommend implementing WHO recommendations for early warning indicators and HIV drug resistance surveys in every national plan for antiretroviral therapy, and to consider funding them through Global Fund grants or reprogramming.”

Dr Shannon Hader, Director of CDC’s Division of Global HIV and Tuberculosis, US Centers for Disease Control and Prevention, added: “The new report pulls together key HIV drug resistance survey findings from across the globe that, taken together with other national-level data, confirm we must be forward-thinking in our efforts to combat resistance: scaling up viral load testing, improving the quality of treatment programs, and transitioning to new drugs like dolutegravir.“

Dr. Hader continued, stating that “Overall high rates of viral suppression across three recent national Population-based HIV Impact Assessments showed that present first-line regimens remain largely effective. However, special attention to populations at risk for higher resistance, such as pediatrics, adolescents, pregnant women and key populations, will be critical to target more urgent interventions. We call on the global community for continued vigilance and responsiveness.”

Note to editors

Key new guidelines and reports will be presented at the International AIDS Society in Paris.

In addition to the Report, Guidelines and the Global action plan on HIV drug resistance, WHO is releasing seven key guidelines and normative tools at the 9th International AIDS Society Conference on HIV Science IAS2017, as follows:

  • A new information note on point-of-care early infant diagnosis assays to support the timely detection of children with HIV.
  • The results of “STAR-self-testing in Africa” an implementation research effort, together with a new landscape report on rapid diagnostic tests for HIV self-testing.
  • A prioritized research agenda for children and adolescents to address low treatment scale-up and quality care for this group.
  • New guidelines on advanced HIV disease and rapid initiation of ART recommending screening, treatment and prophylaxis for major opportunistic infections (such as tuberculosis and cryptococcal disease), and rapid initiation of ART and adherence support for people with advanced HIV.
  • A new report outlining how countries can provide differentiated care tailored services for different needs of patient groups.
  • A new technical update advising countries on what to consider when transitioning to a new treatment regimen, including dolutegravir.
  • An announcement on the findings from INSPIRE, a WHO / Government of Canada collaboration on implementation research which investigates how to ensure mothers return for continuation of care.  
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A Lifetime of Swallowing Pills. 17/7/2017

Published by HEALTHE

Balancing HIV treatment with a myriad of ‘lifestyle’ diseases such as diabetes and hypertension is tricky. Patients have to take lots of pills, some medicines interact badly and there are side effects. But this is the future in our clinics as HIV positive patients age and poor diet and lack of exercise take their toll.

Sister Tresia Nontshinga at Delft Community Health Centre.

It’s a cold winter’s morning at Delft Community Health Centre. Patients huddle under beanies and hoodies, some sitting on scraps of cardboard to ease the chill coming up through the icy plastic seats.

The busy 24-hour clinic sees around 35,000 patients a month from Cape Town’s northern areas, and every morning the corridors and waiting areas are clogged with people.

Infectious diseases – especially tuberculosis and HIV – are the main focus, but the incidence of non-communicable diseases (NCDs) is steadily rising, particularly hypertension and diabetes. Government clinics report that 10,000 new diabetic patients are being diagnosed every month, for example.

By 2025, around 12,3-million South Africans will be on long-term medication for HIV and various NCDs, according to the Department of Health in its Guideline for TB, HIV and NCDs released last year. This is going to put massive strain on the health system, and treatment is particularly challenging for people living with both HIV and NCDs.

“Patients with HIV are living longer and lifestyle diseases are becoming more common in these patients,” says Dr Marcia Vermeulen, who dashes over for a quick chat before attending to a long line of patients.

Seven pills a day

“People are more likely to take their ARVs and be virally suppressed because they have seen the effects if they don’t. But hypertension and diabetes are more abstract,” says Vermeulen. “They can’t see the long-term effects so often don’t adhere to their medication. When we test them, their blood sugar levels are often very high.”

HIV positive patients with NCDs often have to take a lot of pills, which has health workers worried about whether they are going to be able to commit to a lifetime of pill swallowing.

Elizabeth Meyer was first diagnosed with HIV in 2002, but has managed to keep the virus in check for many years and only started ARV treatment a couple of months ago. She is far more plagued by her diabetes and hypertension.

“Two years ago, I was diagnosed with diabetes. My mouth was dry, I had painful burning under my feet,” says the soft-spoken 43-year-old mother.

Meyer now has to take seven pills every day. In the morning, she takes a “big thick” diabetes pill, a blood pressure pill and a cholesterol tablet. She repeats this at night, but adds her daily ARV, which is a three-in-one pill.

“In the beginning, it was hard and I wanted to vomit. I was drowsy and very nauseous but I am getting used to it,” says Meyer. She is also trying hard to cut sugar, salt and fizzy drinks from her diet and watch her weight, which is a constant battle.

Over 6,000 HIV positive patients have started on ARVs at the centre, and around 2,200 are stable with undetectable levels of the virus, says Sister Tresia Nontshinga, the operational manager for infectious diseases.

These stable patients are organised into “clubs” of up to 25 people with similar disease profiles. At the moment, 10 percent of stable HIV positive patients also have chronic diseases. Grouping the diabetic HIV positive patients together, for example, both creates a support system and makes it easier for nurses to address similar problems at the same time.

Medicines interfere

But treating patients with both NCDs and HIV is complicated and it takes much more time for health workers.

For a start, some ARVs – particularly protease inhibitors (PI) – can cause diabetes, in part because the medicine interferes with the body’s absorption of glucose. Luckily, these are “second line” ARVs, taken by people who have become resistant to first line treatment.

“The introduction of dolutegravir in late 2018, which doesn’t impact on glucose, will partly fix this,” says Professor Francois Venter from the Wits Reproductive Health and HIV Institute (WRHI). “We are also working on second line drugs that impact on glucose, to make them safer, which will hopefully become available in 2018 or 2019”.

But there are also the drug interactions between ARVs and NCD medicines to consider. For example, dolutegravir interferes with a diabetes medicine called metformin. The blood-thinning medicine, warfarin, for people in danger of clots, interferes with TB medication.

Delft’s head of clinical services, Dr Sheron Forgus, says that health workers working in infectious diseases have become much more aware of NCDs in the past few years, and are dedicated to screening their HIV positive patients. But it is complicated and time-consuming.

A patient every 12 minutes

Our patients drink litres and litres and litres of fizzy drinks. But the consultations are short and we have to address everything in one visit. To encourage behaviour change, you need at least 30 minutes with each patient.’

Stable HIV positive patients get to see a doctor once a year and these check-ups now take a long time as doctors need to test for NCDs too – which means that they test their “eyes, feet, do blood tests for their sugar levels, cholesterol tests, test their kidneys”, says Forgus.

Each Delft doctor currently see 40 patients a day – that’s a patient every 12 minutes if you work for eight hours flat out without any breaks.

There is very little time to educate patients about healthy habits, particularly related to diet.

“Our patients drink litres and litres and litres of fizzy drinks,” says Forgus. “But the consultations are short and we have to address everything in one visit. To encourage behaviour change, you need at least 30 minutes with each patient. But we are lucky to have a dietician and I have to say that our staff are very dedicated and always go the extra mile for patients.”

Dr Samanta Lalla-Edward, the technical head of NCD research at WRHI, says that while some NCDs are genetic, “the lifestyle and environmentally induced NCDs” have to be addressed as a minimum. These include diseases linked to smoking, excessive alcohol and poor diet “because these are largely within the control of person”.

But, she says, policy makers also need to understand what is driving NCDs, as well as advocate for tighter control over substances such as cigarettes and alcohol, and promote “healthier working and living conditions incorporating nutrition and exercise”.

But it isn’t easy. As Vermeulen says: “Most of our patients are suffer from poor diet and inactivity. They are unemployed and looking for a job, not going to the gym. There are no gyms here.” 

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SA’s New HIV Snag: Patients on ART Think They’re Cured. 14/6/2017

Published by HEALTHE

On the eve of South Africa’s national AIDS conference taking place in Durban this week, Health-e News has found that people are defaulting on their ARVs and posing a risk to others.

A healthcare worker draws a drop of blood for an HIV test. Credit: UNICEF Ethiopia/ 2014/ Pudlowski

Healthcare workers are discovering that HIV patients on treatment sometimes stop taking their medication in the mistaken belief that they have been healed – despite knowing the disease is incurable.

The issue relates to the “undetectable viral load” diagnosis patients receive when their antiretroviral therapy starts working and causes the amount of virus in their blood to drop to an extremely low level.

The confusion arisen because of a misunderstanding of what an “undetectable viral load” actually means. People who hear this result when they go for testing are quick to jump to the wrong conclusion that the virus is no longer in their blood, that they are therefore no longer sick and now have no need for treatment – and they default.

Risky behaviour

A recent snap survey carried out by Health-e News in a rural community in Mpumalanga found that when asked what the words “undetectable virus load” meant, all the respondents said it meant they no longer have HIV.

Themba Ndlovu*, a patient from the City of Mbombela, had blood taken for his CD4 count and viral load to be measured. When the results came back with an undetectable viral load, he assumed he was no longer infected and stopped taking his antiretroviral treatment.

“At first things were fine. And then I started drinking again, smoking and having sex without condom. Even though my partner told me that it was impossible for me to be HIV negative and I should have asked more questions, I ignored her because I thought she was jealous that my virus is gone,” Ndlovu said.

“After months of not taking treatment, and with my bad behaviour, things went from good to bad. I became seriously ill. When I returned to the clinic I was told that I should have not stopped taking my treatment. I was ill because I defaulted,” said Ndlovu.

Undetectable viral load

According to nursing sister Dumisile Shabangu, when a patient has an undetectable viral load, it doesn’t mean the HIV virus is no longer inside their body. It just means that their medication is working and that the amount of virus particles in their blood has dropped so low that they cannot be counted, and they are said to have an “undetectable viral load”.

“For most tests used clinically today, this means fewer than 50 particles of HIV per milliliter of blood. Reaching an undetectable viral load is a key goal of ART. An undetectable viral load means a person is about 96% less likely to transmit the disease,” Shabangu said.

Gugu Ngema also made the hasty decision to stop taking her ARTs.

“English is not my mother tongue and sometimes the explanations we get from nurses are not clear. I remember when I was told about my undetectable viral load, I asked the right questions to found out what this meant. A nurse said to me ‘the virus is not detected in your body and you will not infect another person with the HIV virus’. And so I stopped taking my treatment and defaulted. Then I got sick and lost so much weight and I was embarrassed to go to the clinic, I so began using traditional medicine until my family advised to go back to the clinic before things get any worse,” Ngema said.

Always ask questions

Lay counsellor Zodwa Mbokani said many people stopped taking their treatment when they were told they had an undetectable viral load.

“My advice to all people living with HIV and who are on treatment is to always ask questions and never, ever decide to stop taking medication without your nurse and lay counsellor knowing. The most important thing you must know is that once you start ART, there is no turning back,” Mbokani said.

“Even though we are fully aware that there is no cure for HIV, we feel a decision to stop treatment is rational because we have been praying to live life without the HIV virus. So when we hear the words ‘undetectable viral load’ we feel a rush of emotions and forget to ask the important questions about what exactly it all means,” explained Thandeka Bhengu.

Healthcare workers believe this situation is all too common because of a lack of information about HIV as well as how treatment works, claiming that defaulting on ART’s is the biggest challenge for people living with the virus.

The 8th SA Aids Conference is currently taking place at Durban’s International Conference Centre where it will end on Friday.

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HIV Positive Teens Struggling to Adhere to ARV Treatment. 13/6/2017

Published by HEALTHE

HIV positive teenagers in the Northern Cape have started defaulting on their treatment because of the difficulties they encounter as they regularly have to miss school in order to fetch their medication.

(File Photo)

The situation has sparked calls for more community nurses in the province in order to lengthen clinic operating hours to offer young people the opportunity to get their treatment after school

“We cannot run away from the fact that children living with HIV will grow to be adults tomorrow, and that is why we need to coach and mentor them as well as educate them about positive prevention,” said Nametsegang Gaetsosiwe, a sector leader from People Living with HIV.

“We have notice that as they grow up they start defaulting on their treatment,” Gaetsosiwe said.

A 16-year-old girl explained why she was struggling to continue with her treatment, as it involved her missing school on days she had to go and collect the medication.

“My teacher says I am always asking for permission to be absent , and I told her to go and ask my mother,” the girl said.

“This makes it hard for me to continue with taking treatment because I don’t like explaining myself that much.”

Dikeledi Senatle of Denosa (Democratic Nursing Association of South Africa) in the Northern Cape said a multisectoral, holistic approach was needed to address the problem.

“As Denosa we are advocating for more posts to be made available for nurses so that our facilities can stay open till late. This will grant teenagers enough time to go and collect their treatment after school, and not during school hours. This will help us to keep a learner in class and at the same time help them to adhere to their treatment and ARV’s,” said said.

“Defaulting on HIV treament has implications,“ said family practitioner Doctor Chika Ifebuzor.

“Taking medication for life is not an easy task, especially if you are a child. But breaking treatment also has its own adverse reactions,” he said.

Chika said when a patient stops treatment, the virus multiplies in the system and organs are affected. This could also lead to treatment resistance in the future.

Nthabiseng Andreas from the Department of Social Development said was important for parents raising children with HIV to register them at adherence clubs so that could learn to understand the importance of taking life time medication and also receive the psychosocial support they needed.

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South African Life Expectancy On The Rise. 10/7/2017

Published by BRANDSOUTHAFRICA

Thanks to the world’s largest antiretroviral treatment programme, South Africans’ life expectancy is now 64 years, up from 53 years in 2006 and putting the country on track to achieve the National Development Plan goal of a 70-year life expectancy by 2030.

South Africa now has a population of 56.5-million people, according to the 2017 mid-year population estimates by Statistics South Africa. The country’s population has increased by 902,200 over the past year.

A key finding is that life expectancy is now 64 years. This is an extra decade of projected average lifespan since a decade ago. In 2006, women could expect to live to 54.7 years and men to just 52.3 years, with a population average of 53.5 years.

The gain can be credited to the massive rollout of antiretroviral (ARV) therapy since 2006, according to Stats SA. The country is on track to achieve the National Development Plan goal of a 70-year life expectancy by 2030.

The success of the ARV campaign is also shown in the number of South Africans living with HIV. Today, according to the Stats SA estimates, 7.06-million South Africans are HIV-positive – 13 of every 100 people. That may seem high, but it’s a sign that HIV is being brought under control. It’s also now more of a chronic condition, rather than a fatal one.

“Improved access and uptake of ARVs in South Africa has enabled HIV-positive people to live longer and healthier lives, leading to an increase in the HIV population over time,” Statistician-General Dr Pali Lehohla explained in a presentation of the estimates.

While more people are living with HIV, the rate of infection in young people is dropping. “HIV prevalence among youth aged 18 to 24 has declined from 7.3% in 2002 to 4.6% in 2017,” Lehohla said. “The decline in prevalence among the youth is an indication of decline in the rate of new infections.”

South Africans are living longer

South Africa’s population in 2017

Sex

Of the population of 56.52 million people, 28.9 million are female (51%) and 27.6 million are male (49%).

Population groups

Four out of every five people are black African. Roughly one in 13 fall into the coloured population group, one in 13 are white, and one in every 50 people are Indian South Africans.

  • Black South Africans: 45.7 million (81%)
  • Coloured South Africans: 5 million (9%)
  • White South Africans: 4.5 million (8%)
  • Indian South Africans: 1.4 million (2%)

Population groups in South Africa 2017

Provinces

Gauteng is home to a full quarter of South Africa’s population, and KwaZulu-Natal to almost a fifth. The Northern Cape has only 2% of the population.

  • Gauteng: 14.3 million (25%)
  • KwaZulu-Natal: 11 million (19%)
  • Western Cape: 6.5 million (12%)
  • Eastern Cape: 6.5 million (12%)
  • Limpopo: 5.8 million (10%)
  • Mpumalanga: 4.4 million (8%)
  • North West: 3.9 million (7%)
  • Free State: 2.9 million (5%)
  • Northern Cape: 1.2 million (2%)

Provincial population of South Africa 2017

Children

Thirty percent of South Africans are 15 years or younger.

The working age population in Gauteng is significantly larger than that of the Eastern Cape, which has a younger population with more children.

Limpopo (35%) and the Eastern Cape (34%) have the highest proportion of people aged 15 and under.

Gauteng (25%) and the Western Cape (26%) have the lowest.

Births

The birth rate is an average of 2.41 children per woman, down from 2.73 children per woman in 2007.

“As the rate at which births occur declines, the young dependent population grows smaller in relation to the working-age population,” Lehohla said.

“With more workers and fewer young people to support, a country will have a window of opportunity for accelerated economic growth.”

Mortality

Infant mortality has dropped from 48.1 infant deaths per 1,000 live births in 2002 to 32.8 per 1,000 in 2017.

The crude death rate is down from 13.4 deaths per 1,000 people in 2002 to nine deaths per 1,000 people in 2017.

Migration

Stats SA estimates that from 2016 to 2021, South Africa’s population will be swelled by 1.07-million immigrants from elsewhere in Africa, and 59,432 immigrants from Asia. It also estimates that over the same period, 112,740 white South Africans will emigrate from the country.

Over the past five years, one in every two international migrants has settled in Gauteng.

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SA’s New HIV Challenge: Patients Who Believe They've Been Healed. 13/6/2017

Published by IOL

On the eve of South Africa's national AIDS conference taking place in Durban this week, it has emerged that people are defaulting on their ARVs – often under the impression that they have been healed.

Healthcare workers have discovered that HIV patients on treatment sometimes stop taking their medication in the mistaken belief that they have been healed – despite knowing the disease is incurable – and thus posing a renewed risk to others.

According to health workers Health-e News spoke to, the issue relates to the "undetectable viral load" diagnosis patients receive when their antiretroviral therapy starts working and causes the amount of virus in their blood to drop to an extremely low level.

EXTENDING LIFE: ARVs allow people with HIV to lead a full life. 
Picture: Reuters

People who are informed of the "undetectable viral load" result when they go for testing are quick to jump to the wrong conclusion that the virus is no longer in their blood, that they are therefore no longer sick and no longer have need for treatment – and then default on their treatment.

A recent snap survey carried out by Health-e News in a rural community in Mpumalanga found that when asked what the words "undetectable virus load" meant, all the respondents said it meant they no longer have HIV.

Ben (not their real name), a patient from the City of Mbombela, had blood taken for his CD4 count to be measured.

When the results came back with an undetectable viral load, he assumed he was no longer infected and stopped taking his antiretroviral treatment.

"At first things were fine. And then I started drinking again, smoking and having sex without condom. Even though my partner told me that it was impossible for me to be HIV negative and I should have asked more questions, I ignored her because I thought she was jealous that my virus is gone," he said.

"After months of not taking treatment, and with my bad behaviour, things went from good to bad. I became seriously ill. When I returned to the clinic I was told that I should have not stopped taking my treatment. I was ill because I defaulted."

According to nursing sister Dumisile Shabangu, when a patient has an undetectable viral load, it doesn't mean the HIV virus is no longer inside their body. 

It just means that their medication is working and that the amount of virus particles in their blood has dropped so low that they cannot be counted, and they are said to have an "undetectable viral load".

"For most tests used clinically today, this means fewer than 50 particles of HIV per milliliter of blood. Reaching an undetectable viral load is a key goal of ARV. An undetectable viral load means a person is about 96% less likely to transmit the disease," Shabangu said.

Amanda (not her real name) also made the hasty decision to stop taking her ARVs.

"English is not my mother tongue and sometimes the explanations we get from nurses are not clear. I remember when I was told about my undetectable viral load, I asked the right questions to find out what this meant. A nurse said to me 'the virus is not detected in your body and you will not infect another person with the HIV virus'. And so I stopped taking my treatment and defaulted.

"Then I got sick and lost so much weight and I was embarrassed to go to the clinic, so I began using traditional medicine until my family advised to go back to the clinic before things get any worse," she said.

Lay counsellor Zodwa Mbokani said many people stopped taking their treatment when they were told they had an undetectable viral load.

"My advice to all people living with HIV and who are on treatment is to always ask questions and never, ever decide to stop taking medication without your nurse and lay counsellor knowing. The most important thing you must know is that once you start ART, there is no turning back," Mbokani said.

Another HIV positive patient added: "Even though we are fully aware that there is no cure for HIV, we feel a decision to stop treatment is rational because we have been praying to live life without the HIV virus. So when we hear the words 'undetectable viral load' we feel a rush of emotions and forget to ask the important questions about what exactly it all means."

Healthcare workers believe this situation is all too common because of a lack of information about HIV, as well as how treatment works, claiming that defaulting on ARTs was the biggest challenge for people living with the virus.

The 8th SA Aids Conference is currently taking place at Durban's International Convention Centre and ends on Friday. 

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HIV Is Linked With Impaired Respiratory Health. 6/6/2017

Published by POZ

This remains the case even when HIV is well treated with antiretrovirals.

People living with HIV have a higher risk of impaired respiratory health, even when they are on antiretrovirals (ARVs) and have a fully suppressed viral load.

Publishing their findings in HIV Medicine, researchers conducted a study of 197 people with HIV and 93 people without the virus attending HIV and sexual health outpatient clinics in London in 2015.

The researchers assessed the participants’ respiratory health with the St. George’s Respiratory Questionnaire (SGRQ), their level of breathlessness with the Medical Research Council (MRC) questionnaire on the condition, and their lung function with a spirometry test.

The HIV-positive participants had worse respiratory health. Their median SGRQ total score was 12, compared with 6 among the HIV-negative individuals. Forty-seven percent of HIV-positive participants and 24 percent of HIV-negative participants had an MRC breathless score of 2 or above. A respective 11 percent and 9 percent had airflow obstruction.

After adjusting the data for age, gender, smoking, body mass index and depression, the investigators found that living with HIV was associated with higher SGRQ and MRC scores, including a 2.45-fold increased risk of having an MRC score of at least 2 and a 1.54-fold increased SGRQ score. These findings were similar when those people with HIV who did not have an undetectable viral load were excluded from the analysis.

The researchers concluded: “Despite effective [ARV treatment], impaired respiratory health appears more common in HIV-positive adults, and has a significant impact on health-related quality of life.”

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Starting HIV Treatment. 14/2/2017

Published by POZ

Deciding to start HIV treatment—and figuring out which drugs to start with—is, perhaps, one of the most difficult decisions you will need to make. Learning all you can about the pros and cons of your various treatment options is your best weapon in the fight against HIV. The following information will help you communicate effectively with your doctor as you discuss your treatment options.
 

Why is treatment necessary?
If HIV is allowed to reproduce, or “replicate,” inside the body, it will cause damage to the immune system. Ultimately, the immune system gets so weak that the body becomes vulnerable to other diseases. This is the point at which a person is usually diagnosed with AIDS, and the other diseases they get can eventually cause death. For adults who live in wealthy nations—such as the United States—the average time between becoming infected with HIV and the development of AIDS is 10 years.

This does not, however, include people who take HIV drugs. Clinical trials—studies in which new and old drugs are tested in humans—have repeatedly shown that HIV drugs can keep HIV-infected people alive longer. Treatment, therefore, is a very important option, and people living with the virus should consider starting treatment before HIV has had a chance to do serious damage to their immune systems. Experts believe that people who start HIV treatment while their immune systems are still within normal parameters have the greatest chance of living out something close to a normal life span.

Recent evidence, however, suggests that mild-to-moderate immune damage earlier in the course of disease, as well as inflammation due to actively reproducing virus, might increase a person’s risk for non-AIDS-defining illness such as cardiovascular disease, kidney disease, liver disease and certain cancers. This evidence has prompted experts to recommend treatment earlier than they have done in the past.

HIV treatment is now recommended for all people living with HIV in the United States.

When should treatment be started?
The U.S. Department of Health and Human Services (DHHS)—the federal agency responsible for setting health-related policies in the United States—regularly updates and publishes HIV treatment guidelines to help HIV-positive patients and their health care providers determine when antiretroviral therapy should be started. Here is what the guidelines, last updated in January 2016, recommend:

  • Antiretroviral therapy is recommended for all people living with HIV, regardless of CD4 cell count, to reduce the risk of AIDS- and non-AIDS-related illnesses.
  • Antiretroviral therapy is recommended for people living with HIV for the prevention of HIV transmission.
  • It’s important that HIV-positive individuals are educated on the benefits and risks regarding antiretroviral therapy and address strategies to optimize adherence (e.g., taking medications every day, exactly as prescribed). HIV-positive individuals who may not be able to adhere to treatment (e.g., because of mental health challenges, illicit drug use, other major medical problems, etc.) may elect to defer treatment but it should be started as soon as possible.

Working closely with your health care provider, you can determine when the best time is to start treatment. Though the treatment guidelines recommend antiretroviral is started soon after HIV is diagnosed—the decision to begin therapy also depends on your physical health and your mental readiness to start treatment and stick with it.

In the past, the treatment recommendations were based on an individual’s CD4 cell count. CD4 cells—also known as T-cells, T-helper cells, or T4-cells—belong to a group of white blood cells called lymphocytes. These cells have the double distinction of not only being the primary target of HIV, but also carry the responsibility of coordinating the way in which the immune system responds to disease-causing infections. When the CD4 cell count—the number of cells in a cubic millimeter or milliliter of blood—drops below 200, the immune system is considered to be “compromised” and you are at a higher risk of experiencing an AIDS-related opportunistic infection, like Pneumocystis pneumonia. In fact, immune system damage and certain HIV-related health problems can occur at even higher CD4 cell levels.

A person’s viral load—the amount of HIV in a milliliter of blood—was also widely used to help patients and their health care providers decide when to begin treatment. The higher the viral load, experts suggested, the faster someone might see his or her CD4 cell counts fall to dangerously low levels. Even if a patient had a relatively healthy CD4 count, treatment might still be recommended if he or she had a high viral load. Today, viral load isn’t commonly used to figure out when therapy should be started. But viral load testing is still a routine component of HIV treatment, notably to help patients and their doctors determine if treatment is working correctly.

Do I really need to start HIV treatment immediately?
The recommendation that treatment be started by all U.S. residents living with HIV, regardless of their CD4 cell count, is based on three major goals:

  1. To treat HIV before the virus has had a chance to cause serious damage to the immune system.
  2. To reduce the risk of non-AIDS-related diseases, such as those typically associated with aging, that are becoming increasingly common among people living with HIV.
  3. To reduce the risk of transmitting the virus to others.

Here’s a more detailed look at the potential benefits of early treatment, along with the possible risks:

Potential Benefits

  • Keep your CD4 count high and possibly prevent irreversible damage to the immune system.
  • Decrease your risk of certain HIV-related health problems that can sometimes occur in people with high CD4 counts, including tuberculosis, non-Hodgkin’s lymphoma, Kaposi’s sarcoma, peripheral neuropathy, cancers and pre-cancers caused by human papillomavirus (HPV), and mental deficits seen in some people with HIV, such as difficulty thinking and reasoning (neurocognitive problems).
  • Decrease your risk of serious health problems that occur more frequently in HIV-positive people, such as cardiovascular disease, kidney disease, liver disease, neurological complications and various non-AIDS-related cancers and infections.
  • Reduce your risk of transmitting HIV to others—several studies have confirmed an association between undetectable viral loads and a greatly reduced risk of transmitting the virus, notably during sexual activity and pregnancy. One clinical trial in particular (HPTN 052), involving mixed-status heterosexual couples, found that treating HIV-positive people with ARV drugs reduces the risk of transmitting the virus to HIV-negative sexual partners by 96 percent.

Potential Risks

  • Risk developing treatment-related side effects, including long-term side effects that haven’t yet been discovered.
  • Risk developing HIV drug resistance, resulting in loss of future treatment options.
  • Less time for you to learn about HIV and its treatment, and less time to prepare for adherence to therapy.
  • Increased risk of transmitting drug-resistant HIV to others if you have a detectable viral load while on treatment.

What if I’m pregnant?
Women, whether or not they are pregnant, should be treated using HIV drugs in accordance with their own health needs. In other words, women should not be forced to compromise their own health simply because they are pregnant. Many HIV therapies do, in fact, have a positive impact on the life and health of the baby. Click here for detailed information about pregnancy and HIV.

How do I know my treatment is working?
When HIV drug therapy is started—preferably with a powerful combination of drugs—the level of HIV should start to drop dramatically. This is where viral load testing comes in. During the first two months of therapy, an HIV-infected person’s viral load should drop a minimum of 90 percent. In other words, someone who starts treatment with a viral load count of 100,000 should drop to 10,000 or less within two months. Within 4 to 6 months of starting therapy, the viral load should have dropped a lot more, hopefully below the level of the viral load test’s sensitivity (“undetectable”). Sometimes undetectable means a count less than 400 or 500, but most tests used today can detect as few as 50. Generally, the higher your viral load is before starting therapy, the longer it will take to become undetectable.

As for your CD4 cell count, you will likely see an increase between 100 and 200 cells in the first 12 to 18 months, and can gradually climb from there as long as viral load remains undetectable. Some people who start HIV treatment for the first time have a poor CD4 response despite achieving and maintaining an undetectable viral load. Researchers refer to individuals in this situation as “discordant responders.” Most discordant responders waited to start treatment until their CD4 counts were well below 200. This is one of the reasons that the guidelines recommend starting ARVs earlier.

You and your doctor should continue monitoring your viral load on a regular basis to make sure that the HIV drugs are working properly and that the amount of virus in the blood remains below the level of detection or as low as possible.

If your viral load increases while taking HIV drugs, this may mean that drug resistance has occurred. Click here to learn more about drug resistance.

You should also have your CD4 cell count checked regularly—usually every 3 to 6 months. Additional tests that your health care provider should monitor to ensure that you are not experiencing certain side effects include proteins associated with liver and kidney health, your cholesterol and your blood sugar.

And be sure to discuss with your doctor any problems you are having with your treatment regimen without delay. If you find yourself missing doses or experiencing side effects, you might be able to switch your current regimen for one that is easier to take or associated with fewer side effects. But it is crucial that you do this sooner rather than later.

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