World AIDS 2016
By Dr. Ali Fourkan
On this World AIDS, I want
to remind you of our history. We
are a movement of people who changed the world. Together we
built a unique healthcare infrastructure because nobody would take care of our
friends. We held the hands, comforted the families, and buried our
friends and lovers with dignity, even when many funeral homes refused to
transport them. When local social service agencies turned us away, we
built a network of nonprofits across the country to fight a disease that nobody
cares about. AIDS activism changed the way drugs were approved and laws
were enacted. Activism captured our nation’s attention about a disease
that most people did not want to discuss. Working with our global
friends, we fought to bring treatment to the world, even when everyone said
it’s not possible. All too often we heard the words impossible, you can’t
do it, yet we did. We find ourselves at another great moment of
change. It can seem scary or overwhelming. Our movement needs
strong leaders who understood how to push the system. Leaders who value
inside and outside strategies. Leadership cannot be limited to the few,
it needs to be at all levels of our work, doing a variety of tasks and filling
a diversity of positions.
The HIV movement
depends on government funds to provide medication, healthcare, social services,
housing and support to the 1.2 million Americans living with HIV and prevention
services to reduce the number of new infections that are stubbornly stuck at
around 40,000 annual new HIV-infected individuals. To provide these
needed life-saving services, we must work with President-elect Trump and
Congress. Our movement survived the loss of friends and family. We
learned to stand up when others turned their backs against us. We built
systems of care and prevention services where none previously existed.
During the darkest days of the epidemic, it was our hope and passion that got
us through the difficult times. Because
I know our past, I am not afraid for our future. There will
be difficult moments, but we are a strong vital community that stands on the
shoulders of heroes. NMACthanks everyone
who has dedicated their life to fighting this epidemic.
HIV vaccine
steps closer with new insights into broadly neutralizing antibodies
Scientists reveal new insights into the human body's ability
to produce broadly neutralizing antibodies to HIV that promise to open new
avenues for vaccine development.
Scientists say their new information on broadly neutralizing antibodies may bring us closer to an HIV vaccine.
Scientists say their new information on broadly neutralizing antibodies may bring us closer to an HIV vaccine.
Once the HIV enters the body, the immune system
starts to produce antibodies to fight the pathogen. Generally, the antibodies
produced are specific to the particular strain of HIV.
However, research reveals that around 1 percent of
HIV-infected people produce broadly neutralizing antibodies that attack
different strains of HIV that circulate worldwide.
Broadly neutralizing antibodies bind to structures or
"spikes" on the surface of the virus that arise from the virus itself
and vary little among different strains.
Much of the search for an HIV vaccine focuses on better
understanding how broadly neutralizing antibodies form and attach to the
spikes.
In a paper published in the
journal Nature Medicine, researchers from the University of Zurich
and University Hospital Zurich (UZH) in Switzerland describe how they found
disease-specific, host-specific, and virus-specific factors that appear to
influence the body's ability to make broadly neutralizing antibodies against
HIV.
For the study, the team examined around
4,500 people infected with HIV - all participants of the Swiss HIV Cohort Study
and the Zurich Primary HIV Infection Study. They found 239 of the participants
formed broadly neutralizing antibodies.
Disease, virus, and host factors
The researchers found three important disease-specific
features that appear key for the production of broadly neutralizing antibodies:
the number of viruses present in the body, the diversity of virus types, and
how long the HIV infection had gone untreated.
Huldrych Günthard, professor of clinical infectious diseases
at UZH and one of the study's corresponding authors, says their study is the
first to identify these three disease-specific features.
He says they also found that the features influence the
production of broadly neutralizing antibodies independently of each other, and
explains:
"So we don't necessarily have
to consider all three parameters in designing an HIV vaccine. This is
especially important with regard to the length of vaccine administration - it
wouldn't be possible to imitate a longer untreated HIV infection with a
vaccine."
The important host-specific feature concerns ethnicity. The
team found black participants infected with HIV appear to make broadly
neutralizing antibodies more frequently than white people - regardless of other
factors the study analyzed.
Co-author Alexandra Trkola, a professor of medical virology
at UZH, suggests this factor needs further investigation in order to better
understand how ethnic origin affects production of broadly neutralizing HIV
antibodies. Factors likely to play a role could be genetics, geographics, and
socioeconomics.
Finally, the team found that different virus subtypes appear
to affect the binding site the antibodies attach to. Subtype B viruses are more
likely to spur the body to make HIV antibodies that bind to CD4 binding sites -
through which the virus binds to host immune cells.
In contrast, non-subtype B viruses appear to encourage
production of antibodies that bind to a sugar element of the virus spikes (V2
glycan).
Smoking more hazardous for HIV patients than the virus itself
Cigarette smokers
who are HIV positive appear to have a higher chance of dying from
smoking-related complications than from HIV, according to research published in
the Journal of Infectious Diseases.
Numerous health problems are associated
with smoking. Smokers have a high chance of developing heart disease, cancer, serious lung
diseases, and other infections, such as pneumonia.
Previous research
has suggested that each cigarette shortens a person's lifespan by 11 minutes, and that
smoking from the age of 17-71 years will decrease life expectancy by an average
of 6 ½ years.
HIV is a serious
health condition. Untreated, it can lead to AIDS, which is fatal. Once a person has HIV, it will
never leave their body. HIV affects the body's immune system, so that it can no
longer fight off infections.
In 2014, around
44,073 people were diagnosed with HIV in the United States.
More than 40
percent of people with HIV are smokers, compared with 15 percent for the
general population in the U.S. The number of people with HIV who smoke in the
U.S. is estimated to be around 247,586. Another 20 percent of people with HIV
are former smokers.
HIV patients more prone to the ill effects of tobacco
Current HIV
treatments offer effective protection against the virus, so that people with
the virus are living for longer, but people who have HIV remain especially
susceptible to the risks of smoking.
Pneumocystis
pneumonia, a dangerous lung infection
Chronic
obstructive pulmonary disease (COPD)
Researchers from
Massachusetts General Hospital and Harvard Medical School in Boston, MA,
projected the effects of smoking and HIV on life expectancy.
Patients may lose up to 6.7 years
Using a computer
simulation of HIV disease and treatment, the authors calculated the life
expectancy of people with HIV, based on whether or not they smoked.
Fast facts about HIV and AIDS
From 2005 to
2014, annual diagnoses fell by 19 percent
81 percent of HIV
patients are men.
In the U.S., it
is common for people with HIV to abandon their drug treatment and care regimen.
The current study factored this into the projections, making the results
particularly relevant for U.S. patients and health providers.
Findings showed
that in people with HIV who follow their treatment correctly, smoking decreases
their life expectancy by about twice as much as HIV does.
For men with HIV,
the loss of life expectancy for HIV and for smoking was similar, whether or not
they followed their treatment regime.
Male smokers who
started HIV treatment at the age of 40 years stood to lose 6.7 years of life
expectancy, and women, 6.3 years, compared with those who never smoked. Men who quit
smoking and started
treatment at 40 years would regain 5.7 years of life, and women, 4.6 years.
The authors conclude that people with HIV who follow their
treatment but also smoke are far more likely to die of a smoking-related
disease than from HIV itself.
They call for
smoking cessation to be prioritized for patients with HIV. Helping them to quit
smoking could significantly improve their life expectancy.
Co-author Dr.
Krishna P. Reddy points out that even if a person smokes until the age of 60
years and then quits, they will have a significantly longer life expectancy
than someone who does not quit.
"Now that
HIV-specific medicines are so effective against the virus itself, we also need
to add other interventions that could improve and extend the lives of people
with HIV."
The team calls
for smoking cessation to play a key role in care programs for people living
with HIV. They recommend further research into the best way to help people with
HIV to quit.
They also suggest
investigating the health and economic benefits of quitting smoking among people
living with HIV.
Dr. Keri N.
Althoff, of the Johns Hopkins Bloomberg School of Public Health, comments in an
accompanying editorial: "This study makes clear that we must prioritize
smoking cessation among adults with HIV if we want them to have an increase in
the quantity (and likely quality) of life."
HIV: New, powerful technique finds dormant virus hiding in rare cells
Usually,
antiretroviral drugs control HIV levels in infected people and prevent them
developing full-blown AIDS. However, some viruses stay hidden for years and
flare up if patients cease treatment or if treatment fails. Now, scientists
have discovered a powerful way to wake up dormant HIV and locate the rare cells
that hide it.
Viruses cause
disease by entering host cells and taking over their cell machinery to make
copies of themselves.
HIV targets immune
system cells and weakens people's immunity to infections and ability to fight
some types of cancer.
According to the World Health Organization (WHO), there are
approximately 37 million people worldwide living with HIV, and around 2 million
were newly infected in 2015.
If not treated,
HIV infection progresses to the most advanced stage - Acquired Immunodeficiency
Syndrome (AIDS). This can take 2-15 years, depending on the
individual.
There is no cure
for HIV infection. However, effective antiretroviral (ART) therapy can control
the virus and help prevent transmission.
HIV reservoirs
are cells and tissues where HIV persists, despite ART. The virus mostly lives
and copies itself in CD4+ T lymphocytes, a type of white blood cell.
While ART is
generally successful at controlling the viral load in people with HIV and
stopping them progressing to AIDS, the HIV can stay dormant for years and wakes
up when patients stop their therapy.
Waking up dormant HIV
In the journal Cell Host & Microbe,
researchers from Canada and the United States report how they discovered a way
to reactivate dormant HIV and find the very rare cells that are hiding it.
Fast facts about HIV/AIDS
Estimates suggest
only 54 percent of people with HIV know they have it
During 2000-2015,
new HIV infections fell by 35 percent.
Senior author Dr.
Daniel Kaufmann, associate clinical professor in the department of medicine at
the University of Montreal, says that in order to develop treatments that
target residual infected cells, you have to find precisely where they are in
CD4+ T lymphocyte populations, which are highly variable. He explains:
"Our research has uncovered these HIV hiding places. We were
able to identify and quantify the cells containing hidden virus and then test
drugs to wake up HIV."
With his team,
Dr. Kaufmann, who is also a researcher and infectious disease specialist at the
University of Montreal Hospital Centre (CHUM), developed an innovative way to find the
residual infected cells.
Their method can
be likened to "taking a photograph" of each individual cell harboring
dormant HIV. This represents a significant breakthrough, as it is about 1,000
times more accurate than current technologies.
The team analyzed
blood from 30 patients with HIV, sampled before and after they started on ART.
They were able to detect the virus in CD4+ T lymphocytes in almost all of them.
The idea is that
once you find where dormant HIV is hiding, then you find drugs to wake it up
and make it visible so the immune system or ART can kill it.
In the next phase
of the study, they tested two drugs to wake up the dormant virus - so-called
latency reversal drugs. The drugs, bryostatin and a derivative of ingenol, were
developed to fight cancer but may also be used to fight HIV.
Different patients may need different treatments
The researchers
discovered that the two drugs woke up two different populations of CD4+ T
lymphocytes. They note in particular that the ingenol derivative activated a
population called central memory cells, which can live for years in patients.
Dr. Kaufmann says while their studies were done in the lab,
"a clinical trial would involve using such drugs to wake up the virus
while the patient continues taking ART to ensure that the reactivated virus
cannot infect other cells."
At first the team
assumed HIV hid in similar places in different patients. However, they found
this not to be the case - it varied a lot from patient to patient. Dr. Kaufmann
explains:
"We may have
to adjust the treatment for individual patients, depending on the specific HIV
hiding places in each case. To minimize the virus pools, we will have to assess
patients and tailor the 'shock and kill' therapies to their profiles."
The team's next
step is to evaluate the effectiveness of new drugs to wake up similar virus
reservoirs in monkeys. If the drugs are well tolerated, then clinical trials in
humans can go ahead in a few years.
HIV update - 7th December 2016
NHS England will
make PrEP available next year
NHS England and Public Health England
have given an outline of a large study of the best way
for the NHS to implement pre-exposure prophylaxis (PrEP), which is due to start
in the middle of next year. This follows the Court of Appeal’s ruling last
month that NHS England, alongside local authorities, has the power, but not the
obligation, to fund PrEP and should plan how to provide it.
While many
activists would have preferred the NHS to announce an immediate roll-out of
PrEP to all who need it, there was also the risk that the NHS would have
decided that PrEP was too expensive to provide at the moment.
The study may
allow a significant number of people to get access to PrEP – around 10,000
people may take part over a three-year period. A large trial may be possible
because NHS England and Public Health England are trying to drive the price of
PrEP drugs down by pitting generic companies and Gilead (the pharmaceutical
company that produces Truvada)
against each other in a bidding war.
We know that the
study will not be directed exclusively at gay men or any other population, but
very few details of the trial have been settled. It is not clear whether the
trial will be run at sexual health clinics across England, or only in a few
selected locations.
Deborah Gold of
the National AIDS Trust, which took NHS England to court, said that the trial
would not be happening without the legal challenge, a series of parliamentary
questions and strong community pressure for PrEP. “We are absolutely delighted
that following our wins in Court, NHS England, working with Public Health
England and local government will be now making PrEP available on a large
scale, and quickly, to those who need it,” she said.
Greg Owen
of iwantPrEPnow welcomed the announcement but said that the plans are
not a permanent solution to wider PrEP provision. He called on NHS England
to ensure that the limited availability of PrEP is targeted so it does not
worsen existing health inequalities.
Real-world data
on hepatitis C treatment for people living with HIV
More than 90% of
HIV-positive people treated with direct-acting antivirals for hepatitis C were
cured of hepatitis C and few stopped treatment due to side-effects, showing
that real-world clinical practice can produce results as good as those seen in
formal clinical trials, according to Spanish data.
People who take
part in clinical trials are not always typical of other patients, and they also
get extra monitoring and support. For that reason, there is a possibility that
results in clinical trials will be better than in routine medical care.
But these data
provide reassurance on that point. They show that people living with HIV can
have excellent results with modern hepatitis C drugs.
In Madrid,
doctors are obliged to record details of all patients who have HIV and
hepatitis C co-infection. The analysis therefore includes all 2300 people in
Madrid who started hepatitis C treatment over an 18-month period. Most were men
and their average age was 50. Importantly, just under half had cirrhosis,
indicating significant damage to the liver.
The drugs most
commonly used were:
Sofosbuvir and
ledipasvir (Harvoni combined
tablet)
Sofosbuvir (Sovaldi)
and daclatasvir (Daklinza)
the
paritaprevir-based '3D' regimen (Viekirax + Exviera).
Overall, 92% of
people had a continued undetectable hepatitis C viral load 12 weeks after
completing treatment (i.e. sustained virological response or SVR12). This
outcome suggests that the person has been cured of hepatitis C. Cure rates were
similar between people with genotypes 1a, 1b, 3 and 4.
People with
compensated cirrhosis (the earlier stage of cirrhosis, during which the liver
is damaged but still able to perform most of its functions) had cure rates
almost as good as those without cirrhosis. However, in people with
decompensated cirrhosis (the later stage), cure rates were lower at 81%.
Less than 1% of
people stopped treatment because of side-effects.
The results
confirm that treatment outcomes are similar for people with co-infection and
for people with hepatitis C alone.
Top 10 HIV
Clinical Developments of 2016
In typical years,
a noteworthy development in the world of HIV would be the result of a landmark
clinical trial or perhaps a gem of a lab study with a novel finding. But, 2016
was not typical. What made the most difference for people living with HIV and
their health care providers this past year was less a paper published or
presented than major shifts in our thinking about how best to prevent and
manage HIV infection.
This was the year
of the "shake-up" and the eschewing of the good-enough status quo.
HIV-positive patients and their providers, traditionally cautious in their
approach to treatment, have recently become willing to embrace change,
including to antiretroviral regimens. "Switch and simplification"
have replaced "stay the course" as a guiding HIV therapeutics mantra.
New drugs and formulations offer treatment options that are markedly easier and
safer than the medications on hand just a year or two ago. Even the dogma
regarding what constitutes highly active antiretroviral therapy (ART) is being
questioned by daring ART minimalists for whom fewer drugs mean lower risks and
costs. At the same time, the movement that advocated successfully for earlier
administration of HIV therapy is now pushing for provision of medications the
same day a patient presents for testing. For all this radicalism, there were
also throwbacks to retro ideas, such as using antibodies to fight HIV -- an
approach that was tried but failed early in the epidemic.
Overshadowing
this evolution of thought were the results of the presidential election and the
delivery of control of both the House and Senate, as well as a few
governorships, to the Republican Party. Perhaps no other development will have
as much impact (think: comet, dinosaurs) on the future of people living with
HIV as the 2016 elections -- and that is where we start.
Source of Table
of Contents
David Alain Wohl,
M.D., is a professor in the Division of Infectious Diseases at the University
of North Carolina at Chapel Hill, director of the North Carolina AIDS Training
and Education Center and site leader of the University of North Carolina Chapel
Hill AIDS Clinical Research Site.
The
writer Teacher & Columnist
8801611579267
Dr.fourkanali@gmail.com
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