HIV This Week: what scientific journals said

Welcome to the 82nd issue of HIV This Week ! In this issue, we cover the following topics: 1. Refugees and internally displaced persons Tracking country commitment to people displaced by conflict Why internal migrants should not be left behind 2. Epidemiology Likoma, Malawi: lessons from a small island on sexual networks Measuring HIV mortality in India 3. Financing What do fungibility and sub-additionality have to do with country ownership? 4. Vaccines The epitope holy grail: Three long-term survivors help us discover a structurally conserved and immunogenic region of HIV Mosaic vaccines produce immune responses to diverse HIV strains in monkeys 5. Tuberculosis What works in tuberculosis treatment for people living with HIV 6. Universal Access Where and just how bad is coverage of HIV prevention, treatment, and care services for people who inject drugs? 7. Men who have sex with men Acceptability of anal Pap testing to prevent anal cancer: should it become part of routine care? 8. Co-Morbidity: HIV and Worms Helminth co-infection in people living with HIV in Kenya: time for diagnosis, deworming. and prevention Tanzanian adolescents with schistosomiasis have high false positive HIV test results 9. PMTCT Starting antiretroviral therapy in South Africa before pregnancy reduces transmission but preventing unplanned pregnancy could do even more A single founder virus gets through in perinatally infected Zambian infants 10. Human Rights Drug control undermines pain control: widespread and needless suffering at the end of life 11. Treatment What drugs work best in HIV-2 in West Africa? Less than annual viral load testing in Asia linked to poor prognosis 12. Orphans and HIV Rural Zimbabwe orphans in school run increased HIV risks

Cate Hankins Chief Scientific Adviser to UNAIDS

Precious Lunga Research officer

Tania Lemay Research consultant

Gladys Tagi Assistant

To find out how you can access a majority of scientific journals free of charge, please see the last page of this issue or check the HIV This Week website clicking here. If you are reading this through the kindness of a friend and would like to subscribe to receive HIV This Week pdf issues by email, you can sign up by clicking here. To unsubscribe, please click the following link: unsubscribe. We want to be as helpful to you as we can, so please let us know what your interests are and what you think of HIV This Week by sending a comment to hivthisweek@unaids.org or by posting one on the HIV This Week weblog. If you would like to recommend an article for inclusion, please contact HIV This Week here. Dont forget that you can find a wealth of information on the HIV epidemic and responses to it at www.unaids.org.

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1. Refugees and Internally displaced persons Conflict-affected displaced persons need to benefit more from HIV and malaria national strategic plans and Global Fund grants. Spiegel PB, Hering H, Paik E, Schilperoord M. Confl Health. 2010;4:2 Access to HIV and malaria control programmes for refugees and internally displaced persons is not only a human rights issue but a public health priority for affected populations and host populations. The primary source of funding for malaria and HIV programmes for many countries is the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). This article analyses the current HIV and malaria National Strategic Plans and Global Fund approved proposals from rounds 1-8 for countries in Africa hosting populations with refugees and/or internally displaced persons to document their inclusion. The review was limited to countries in Africa as they constitute the highest caseload of refugees and internally displaced persons affected by HIV and malaria. Only countries with a refugee and/or internally displaced persons population of >/= 10,000 persons were included. National Strategic Plans were retrieved from primary and secondary sources while approved Global Fund proposals were obtained from the organisation's website. Refugee figures were obtained from the United Nations High Commissioner for Refugees' database and internally displaced persons figures from the Internal Displacement Monitoring Centre. The inclusion of refugees and internally displaced persons was classified into three categories: 1) no reference; 2) referenced; and 3) referenced with specific activities. A majority of countries did not mention internally displaced persons (57%) compared with 48% for refugees in their HIV National Strategic Plans. For malaria, refugees were not included in 47% of National Strategic Plans compared with 44% for internally displaced persons. A minority (21-29%) of HIV and malaria National Strategic Plans referenced and included activities for refugees and internally displaced persons. There were more approved Global Fund proposals for HIV than malaria for countries with both refugees and internally displaced persons, respectively. The majority of countries with >/=10,000 refugees and internally displaced persons did not include these groups in their approved proposals (61%-83%) with malaria having a higher rate of exclusion than HIV. Countries that have signed the 1951 refugee convention have an obligation to care for refugees and this includes provision of health care. Internally displaced persons are citizens of their own country but like refugees may also not be a priority for Governments' National Strategic Plans and funding proposals. Besides legal obligations, Governments have a public health imperative to include these groups in National Strategic Plans and funding proposals. Governments may wish to add a component for refugees that is additional to the needs for their own citizens. The inclusion of forcibly displaced persons in funding proposals may have positive direct effects for host populations as international and United Nations agencies often have strong logistical capabilities that could benefit both populations. For National Strategic Plans, strong and concerted advocacy at global, regional and country levels needs to occur to successfully ensure that affected populations are included in their plans. It is essential for their inclusion to occur if we are to reach the stated goal of universal access and the Millennium Development Goals.
For full text access click here: http://www.conflictandhealth.com/content/4/1/2

Editors Note: Despite public commitments by 189 countries to incorporate refugees and internally displaced persons in national HIV strategies, only Egypt and Sierra Leone have included activities for refugees in both their HIV national strategic plans (NSP) and approved Global Fund proposals. Out of 33 African countries with more than 10,000 refugees, 6 countries included them in NSP and 8 in approved Global Fund proposals. Out of 22 countries with more than 10,000 internally displaced persons, 3 countries included them in NSP and 5 in approved Global Fund proposals. This is surprising because refugees and internally displaced persons are often located in isolated and inaccessible areas where government services for the local population are usually poor and where funding proposals for integrated services could have positive direct effects for host populations. Thus, in addition to human rights principles and a public health rationale, there is a straightforward pragmatic health services strengthening justification for addressing the needs of conflict-affected displaced persons.

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Within but without: human rights and access to HIV prevention and treatment for internal migrants.
Todrys KW, Amon JJ. Global Health. 2009;5:17

Worldwide, far more people migrate within than across borders, and although internal migrants do not risk a loss of citizenship, they frequently confront significant social, financial and health consequences, as well as a loss of rights. The recent global financial crisis has exacerbated the vulnerability internal migrants face in realizing their rights to health care generally and to antiretroviral therapy in particular. For example, in countries such as China and Russia, internal migrants who lack official residence status are often ineligible to receive public health services and may be increasingly unable to afford private care. In India, internal migrants face substantial logistical, cultural and linguistic barriers to HIV prevention and care, and have difficulty accessing treatment when returning to poorly served rural areas. Resulting interruptions in HIV services may lead to a wide range of negative consequences, including: individual vulnerability to infection and risk of death; an undermining of state efforts to curb the HIV epidemic and provide universal access to treatment; and the emergence of drug-resistant disease strains. International human rights law guarantees individuals lawfully within a territory the right to free movement within the borders of that state. This guarantee, combined with the right to the highest attainable standard of health set out in international human rights treaties, and the fundamental principle of non-discrimination, creates a duty on states to provide a core minimum of health care services to internal migrants on a nondiscriminatory basis. Targeted HIV prevention programs and the elimination of restrictive residencebased eligibility criteria for access to health services are necessary to ensure that internal migrants are able to realize their equal rights to HIV prevention and treatment.
For full text access click here: http://www.globalizationandhealth.com/content/5/1/17

Editors Note: Far more people migrate within their country than out of it. China has more than 140 million and India more than 250 million internal migrants. Internal migrants change residence from one civil division to another in their country of origin for social, political, or financial reasons or in the wake of natural disaster. This article highlights the negative health consequences of internal registration systems, such as hukuo (China) and propiska (Russia) or state-specific government ration cards (India), which are compounded by deepening health and social inequalities in the wake of the global financial crisis. The lack of access to and lack of continuity in antiretroviral treatment services for internal migrants, who are often doubly stigmatised, along with gaps in HIV prevention programmes, are creating the conditions for failure to reach national goals of reduced HIV incidence and disease burden. The right to the highest attainable standard of health, the principle of non-discrimination, and the right to free movement within state borders are all international human rights law guarantees to which signatory countries are legally bound. Immediate steps to end discrimination in health care provision for internal migrants should be high on every countrys agenda. 2. Epidemiology The Likoma Network Study: Context, data collection, and initial results.
Helleringer S, Kohler HP, Chimbiri A, Chatonda P, Mkandawire J. Demogr Res. 2009;21:427-468

The extent and structure of sexual networks have important consequences for the spread of sexually transmitted diseases such as HIV. However, very few datasets currently exist that allow a detailed investigation of sexual networks in sub-Saharan African settings where HIV epidemics have become generalized. In this paper, the authors describe the context and methods of the Likoma Network Study, one of the few studies that have collected extensive information on sexual networks in sub-Saharan Africa. They start by reviewing theoretical arguments and empirical studies emphasizing the importance of network structures in the epidemiology of HIV and other sexually transmitted infections. The island setting of this study is described, and the authors argue that the choice of an island as a research site limited potential biases that may make the collection of sexual network data difficult. Helleringer and colleagues then document their empirical strategy for the collection of sexual network data and the

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subsequent identification of sexual network partners. A description of the protocol for the collection of biomarker data (HIV infection) is provided. Finally, they present initial results relating to the socioeconomic context of the island, the size and composition of sexual networks, the quality of the sexual network data, the determinants of successful contact tracing during the Likoma Network Study, and the prevalence of HIV in the study population. For full text access click here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825888/?tool=pubmed Editors note: Although Likoma Island in Lake Malawi is 18 square kilometres and has a population of only 7000 people living in a dozen villages, it has contributed substantially to our understanding of the role of sexual networks in generalized epidemics. Only 7 of 1235 households refused to be interviewed about socioeconomic information and in the seven villages chosen for the sexual network survey (representing 50.9% of 18-35 year olds on Likoma), the participation rate was 88%. Whereas Demographic and Heath Surveys are egocentric, meaning that they rely on self-reports that have to be taken at face value, the Likoma Study is socio-centric. It provides detailed data on the extent and structure of sexual networks and evaluates data quality by determining rates of inter-partner agreement about sexual relationships. Understanding patterns of connectivity and overlap between relationships informs modelling of the sexual spread of HIV and can assist in the design of context-appropriate HIV prevention programmes. A big challenge is to explain how individuals are part of sexual networks, even if they themselves have only one partner. HIV mortality and infection in India: estimates from nationally representative mortality survey of 1.1 million homes.
Jha P, Kumar R, Khera A, Bhattacharya M, Arora P, Gajalakshmi V, Bhatia P, Kam D, Bassani DG, Sullivan A, Suraweera W, McLaughlin C, Dhingra N, Nagelkerke N; Million Death Study Collaborators. BMJ 2010;340:c62

The aim of the study was to determine the rates of death and infection from HIV in India by analysing a nationally representative survey of deaths. The study population covered 1.1 million homes in India. The population included 123,000 deaths at all ages from 2001 to 2003. The main outcomes were HIV mortality and infection. HIV accounted for 8.1% (99% confidence interval 5.0% to 11.2%) of all deaths among adults aged 25-34 years. In this age group, about 40% of deaths from HIV were due to AIDS, 26% were due to tuberculosis, and the rest were attributable to other causes. Nationally, HIV infection accounted for about 100,000 (59,000 to 140,000) deaths or 3.2% (1.9% to 4.6%) of all deaths among people aged 15-59 years. Deaths from HIV were concentrated in the states and districts with higher HIV prevalence and in men. The mortality results imply an HIV prevalence at age 15-49 years of 0.26% (0.13% to 0.39%) in 2004, comparable to results from a 2005/6 household survey that tested for HIV (0.28%). Collectively, these data suggest that India had about 1.4-1.6 million HIV infected adults aged 15-49 years in 2004-6, about 40% lower than the official estimate of 2.3 million for 2006. All cause mortality increased in men aged 25-34 years between 1997 and 2002 in the states with higher HIV prevalence but declined after that. HIV prevalence in young pregnant women, a proxy measure of incidence in the general population, fell between 2000 and 2007. Thus, HIV mortality and prevalence may have fallen further since this study. HIV attributable death and infection in India is substantial, although it is lower than previously estimated.
For full text access click here: http://www.bmj.com/cgi/content/full/340/feb23_2/c621?view=long&pmid=20179131

Editors note: What is important about this study is not the impressively large numbers 900 field interviewers recorded symptoms, signs, and key circumstances leading to death for 132, 626 deaths that occurred in a nationally representative sample of 1.1 million homes. Rather, it is that setting up a sample registration system from a national census, as the Government of India has done, creates a framework for reporting causes of death through household visits. This information can be triangulated with data from

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cohort studies of people living with HIV, results of demographic and health surveys that include HIV testing, sentinel surveillance using HIV testing, and other data to improve national monitoring of HIV and measure the population-level impact of prevention and treatment services. 3. Financing Public financing of health in developing countries: a cross-national systematic analysis.
Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJ. Lancet. 2010;375:1375-87

Government spending on health from domestic sources is an important indicator of a government's commitment to the health of its people, and is essential for the sustainability of health programmes. The study aimed to systematically analyse all data sources available for government spending on health in developing countries; describe trends in public financing of health; and test the extent to which they were related to changes in gross domestic product (GDP), government size, HIV prevalence, debt relief, and development assistance for health to governmental and non-governmental sectors. The authors did a systematic analysis of all data sources available for government expenditures on health as agent (GHE-A) in developing countries, including government reports and databases from WHO and the International Monetary Fund (IMF). GHE-A consists of domestically and externally financed public health expenditures. They assessed the quality of these sources and used multiple imputation to generate a complete sequence of GHE-A. With these data and those for development assistance for health to governments, the authors estimated government spending on health from domestic sources. They used panel-regression methods to estimate the association between government domestic spending on health and GDP, government size, HIV prevalence, debt relief, and development assistance for health disbursed to governmental and non-governmental sectors. The authors tested the robustness of our conclusions using various models and subsets of countries. In all developing countries, public financing of health in constant US$ from domestic sources increased by nearly 100% (IMF 120%; WHO 88%) from 1995 to 2006. Overall, this increase was the product of rising GDP, slight decreases in the share of GDP spent by government, and increases in the share of government spending on health. At the country level, while shares of government expenditures to health increased in many regions, they decreased in many sub-Saharan African countries. The statistical analysis showed that development assistance for health to government had a negative and significant effect on domestic government spending on health such that for every US$1 of development assistance for health to government, government health expenditures from domestic resources were reduced by $0.43 (p=0) to $1.14 (p=0). However, development assistance for health to the non-governmental sector had a positive and significant effect on domestic government health spending. Both results were robust to multiple specifications and subset analyses. Other factors, such as debt relief, had no detectable effect on domestic government health spending. To address the negative effect of development assistance for health on domestic government health spending, Lu and colleagues recommend strong standardised monitoring of government health expenditures and government spending in other health-related sectors; establishment of collaborative targets to maintain or increase the share of government expenditures going to health; investment in the capacity of developing countries to effectively receive and use development assistance for health; careful assessment of the risks and benefits of expanded development assistance for health to nongovernmental sectors; and investigation of the use of global price subsidies or product transfers as mechanisms for development assistance for health.
For full text access click here: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B4YTBT7Y4&_user=8658645&_coverDate=04%2F23%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d &_docanchor=&view=c&_acct=C000055308&_version=1&_urlVersion=0&_userid=8658645&md5=28c386e 5cd3dcd64d0421ff4aca9133c

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Editors note: Fungibility of foreign aid occurs when aid substitutes for government spending, resulting in sub-additionality rather additionality, the goal of most development assistance. Among the factors that are complicating discussions of its extent, and what to do about it, are incomplete estimates of development assistance for health (DAH) in the first place (untraceable DAH), variations in accounting practices at country level for total health expenditures, and lack of information about what the resources taken from ministries of health actually are spent on. Although African leaders pledged in 2001 in Abuja to devote 15% or more of their yearly budgets to the health sector and absolute amounts of domestic funding being spent on health have increased 132-242% between 1995 and 2006 in low-income countries in sub-Saharan Africa, the largest reductions in the proportion that domestic funding contributes to health spending occurred in countries with the largest HIV epidemics and the largest DAH contributions. It is not surprising that increasing domestic contributions are overshadowed by external support as countries try to turn around HIV epidemics that are sapping development. Although investment in effective public expenditure management systems is clearly needed to improve accountability from the global level right through to local level, it is important to remember that country ownership starts with nationally set priorities and reallocation of funding to match these. 4. Vaccines Neutralization of genetically diverse HIV-1 strains by IgA antibodies to the gp120-CD4-binding site from long-term survivors of HIV infection.
Planque S, Salas M, Mitsuda Y, Sienczyk M, Escobar MA, Mooney JP, Morris MK, Nishiyama Y, Ghosh D, Kumar A, Gao F, Hanson CV, Paul S. AIDS. 2010;24:875-84

The aim of the study was to identify an HIV epitope suitable for vaccine development. Diverse HIV-1 strains express few structurally constant regions on their surface vulnerable to neutralizing antibodies. The mostly conserved CD4-binding site of gp120 is essential for host cell binding and infection by the virus. Antibodies that recognize the CD4-binding site are rare, and one component of the CD4-binding site, the 421-433 peptide region, expresses B-cell superantigenic character, a property predicted to impair the anti-CD4binding site adaptive immune response. IgA samples purified from the plasma of patients with HIV infection were analyzed for the ability to bind synthetic mimetics containing the 416-433 gp120 region and full-length gp120. Infection of peripheral blood mononuclear cells by clinical HIV isolates was measured by p24 ELISA. IgA preparations from three patients with subtype B infection for 19-21 years neutralized heterologous, coreceptor CCR5-dependent subtype A, B, C, D, and AE strains with exceptional potency. The IgAs displayed specific binding of a synthetic 416-433 peptide mimetic dependent on recognition of the CD4-binding residues located in this region. Immunoadsorption, affinity chromatography, and mutation procedures indicated that HIV neutralization occurred by IgA recognition of the CD4-binding site. These observations identify the 421-433 peptide region as a vulnerable HIV site to which survivors of infection can produce powerful neutralizing antibodies. This indicates that the human immune system can bypass restrictions on the adaptive B cell response to the CD4-binding site, opening the route to targeting the 421-433 region for attaining control of HIV infection.
For abstract access click here: http://journals.lww.com/aidsonline/pages/articleviewer.aspx?year=2010&issue=03270&article=00010&typ e=abstract

Editors note: Studying the immune response of 3 long-term survivors, who had contracted HIV as children from contaminated blood products 19-21 years previously, revealed a region of HIV that is structurally conserved in genetically diverse HIV strains around the world and is immunogenic, meaning that it stimulates a robust immune response. Purified plasma IgA preparations from each of these 3 patients who were infected with sub-type B neutralized 18 genetically diverse clinical isolates from subtypes A, B, C, D, and AE. This is exciting news because the search for such a conserved epitope, i.e. the part of the virus that

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is recognized by the immune system and to which an antibody binds, is a holy grail. The site is the 421-433 region of the CD4 binding site of the virus. Interestingly, the autoimmune disease systemic lupus erythematosus produces antibodies to this epitope - and HIV and lupus rarely co-exist. Mosaic vaccines elicit CD8(+) T lymphocyte responses that confer enhanced immune coverage of diverse HIV strains in monkeys.
Santra S, Liao HX, Zhang R, Muldoon M, Watson S, Fischer W, Theiler J, Szinger J, Balachandran H, Buzby A, Quinn D, Parks RJ, Tsao CY, Carville A, Mansfield KG,Pavlakis GN, Felber BK, Haynes BF, Korber BT, Letvin NL. Nat Med. 2010;16:324-8

An effective HIV vaccine must elicit immune responses that recognize genetically diverse viruses. It must generate CD8(+) T lymphocytes that control HIV replication and CD4(+) T lymphocytes that provide help for the generation and maintenance of both cellular and humoral immune responses against the virus. Creating immunogens that can elicit cellular immune responses against the genetically varied circulating isolates of HIV presents a key challenge for creating an HIV vaccine. Polyvalent mosaic immunogens derived by in silico recombination of natural strains of HIV are designed to induce cellular immune responses that recognize genetically diverse circulating virus isolates. Here Santra and colleagues immunized rhesus monkeys by plasmid DNA prime and recombinant vaccinia virus boost with vaccine constructs expressing either consensus or polyvalent mosaic proteins. As compared to consensus immunogens, the mosaic immunogens elicited CD8(+) T lymphocyte responses to more epitopes of each viral protein than did the consensus immunogens and to more variant sequences of CD8(+) T lymphocyte epitopes. This increased breadth and depth of epitope recognition may contribute both to protection against infection by genetically diverse viruses and to the control of variant viruses that emerge as they mutate away from recognition by cytotoxic T lymphocytes.
For abstract access click here: http://www.nature.com/nm/journal/v16/n3/abs/nm.2108.html

Editors note: In this macaque study, a mosaic immunogen was created by combining the gag and nef genes from geographically and sub-type diverse natural strains of HIV. A much broader immune response was elicited in macaques with this recombinant mix than with a consensus protein. Cellular immune responses to mosaic immunogens recognized a greater diversity of viral epitope variants, with CD+8 T lymphocytes showing significantly greater cross-reactivity, not only to more epitopes but also to more variant sequences of specific epitopes. Keeping up with viral evolution means expanding the breadth and depth of our CD8+ cytotoxic T lymphocyte responses it looks like mosaic vaccines may be able to give us the leg up that we will need. 5. Tuberculosis Treatment of Active Tuberculosis in HIV-Coinfected Patients: A Systematic Review and MetaAnalysis.
Khan FA, Minion J, Pai M, Royce S, Burman W, Harries AD, Menzies D. Clin Infect Dis. 2010; 50:1288-99

Patients with human immunodeficiency virus (HIV) infection and tuberculosis have an increased risk of death, treatment failure, and relapse. A systematic review and meta-analysis of randomized, controlled trials and cohort studies was conducted to evaluate the impact of duration and dosing schedule of rifamycin and use of antiretroviral therapy in the treatment of active tuberculosis in HIV-positive patients. In included studies, the initial tuberculosis diagnosis, failure, and/or relapse were microbiologically confirmed, and patients received standardized rifampin- or rifabutin-containing regimens. Pooled cumulative incidence of treatment failure, death during treatment, and relapse were calculated using random-effects models. Multivariable meta-regression was performed using negative binomial regression. After screening 5158 citations, 6 randomized trials and 21 cohort studies were included. Relapse was more common with regimens using 2 months rifamycin (adjusted risk ratio, 3.6; 95% confidence interval, 1.1-11.7) than with UNAIDS_CSA-RO_HIVthisweek_82_100621

regimens using rifamycin for at least 8 months. Compared with daily therapy in the initial phase patients from 35 study arms), thrice-weekly therapy (patients from 5 study arms) was associated with higher rates of failure (adjusted risk ratio, 4.0; 95% confidence interval, 1.5-10.4) and relapse [adjusted risk ratio, 4.8; 95% confidence interval, 1.8-12.8). There were trends toward higher relapse rates if rifamycins were used for only 6 months, compared with 8 months, or if antiretroviral therapy was not used. This review raises serious concerns regarding current recommendations for treatment of HIVtuberculosis coinfection. The data suggest that at least 8 months duration of rifamycin therapy, initial daily dosing, and concurrent antiretroviral therapy might be associated with better outcomes, but adequately powered randomized trials are urgently needed to confirm this.
For full text access click here: http://www.journals.uchicago.edu/doi/full/10.1086/651686

Editors Note: Treatment failure in tuberculosis can be due to true relapse (recurrence of TB with the initial strain) or reinfection (recurrence with a new strain). It is important to distinguish clearly between these two but that requires DNA fingerprinting. It was performed, incompletely, in only 4 of the 27 studies meeting the meta-analysis eligibility criteria. The most striking finding of this analysis is the paucity of adequately powered, well-designed, and well-executed randomized controlled trials on treatment of HIV-TB coinfection. With the mortality rate in HIV-infected patients 6 times higher than in HIV-negative patients, it is urgent to investigate strategies to align these. Daily therapy in the intensive phase (first 2 months) and longer duration of rifamycin treatment clearly were associated with lower rates of failure and/or relapse. Although receipt of antiretroviral therapy was associated with nonsignificantly lower rates of failure and relapse, the SAPIT trial makes clear that initiation of antiretroviral treatment should not wait until the end of tuberculosis treatment (see HIV This Week Issue 79). 6. Universal Access HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage.
Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, Myers B, Ambekar A, Strathdee SA; for the 2009 Reference Group to the UN on HIV and Injecting Drug Use. Lancet. 2010; 375:1014-28

Previous reviews have examined the existence of HIV prevention, treatment, and care services for persons who inject drugs worldwide, but they did not quantify the scale of coverage. Mathers and colleagues undertook a systematic review to estimate national, regional, and global coverage of HIV services in people who inject drugs. The authors did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for persons who inject drugs: needle and syringe programmes, opioid substitution therapy and other drug treatment, HIV testing and counselling, antiretroviral therapy, and condom programmes. They calculated national, regional, and global coverage of needle and syringe programmes, opioid substitution therapy, and antiretroviral therapy on the basis of available estimates of persons who inject drugs population sizes. By 2009, needle and syringe programmes had been implemented in 82 countries and opioid substitution therapy in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle-syringes per individuals who inject drugs per year) had by far the greatest rate of needlesyringe distribution; Latin America and the Caribbean (0.3 needle-syringes per individuals who inject drugs per year), Middle East and north Africa (0.5 needle-syringes per individuals who inject drugs per year), and sub-Saharan Africa (0.1 needle-syringes per individuals who inject drugs per year) had the lowest rates. Opioid substitution therapy coverage varied from less than or equal to one recipient per 100 persons who inject drugs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 individuals who inject drugs). The number of persons who inject drugs receiving antiretroviral therapy varied from less than one per 100 HIV-

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positive persons who inject drugs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive persons who inject drugs in six European countries. Worldwide, an estimated two needle-syringes (range 1-4) were distributed per persons who inject drugs per month, there were eight recipients (6-12) of opioid substitution therapy per 100 persons who inject drugs, and four persons who inject drugs (range 2-18) received antiretroviral therapy per 100 HIV-positive persons who inject drugs. Worldwide coverage of HIV prevention, treatment, and care services in persons who inject drugs populations is very low. There is an urgent need to improve coverage of these services in this population at higher risk from HIV.
For full text access click here: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4YGM2VP1&_user=8658645&_coverDate=03%2F26%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanc hor=&view=c&_acct=C000055308&_version=1&_urlVersion=0&_userid=8658645&md5=cd4501c30880b5d 7acf91165a537bc3e

Editors note: Although the number of countries with core HIV prevention services (needle-syringe programmes [NSP], opioid substitution therapy [OST], and antiretroviral therapy[ART]) for people who inject drugs is growing, coverage is highly variable and it remains very poor in the majority of countries. Outside of sub-Saharan Africa, one-third of all HIV infections are acquired through injecting with contaminated equipment. Unless there is concerted action to address the risk environments that decrease the likelihood that sterile injecting equipment can be used, HIV transmission through injecting will continue to flourish. Rapid expansion of coverage for the 9 core interventions identified as essential by UNODC, WHO, and UNAIDS is urgently needed. In addition to NSP, OST, and ART, these are voluntary counselling and testing; prevention and treatment of sexually transmitted infections; condom programming for injecting drug users and partners; tailored information, education and communication; vaccination, diagnosis, and treatment of viral hepatitis; and prevention, diagnosis, and treatment of tuberculosis. New interventions are not needed, rather policies to increase implementation of proven HIV programmes clearly are and that will require that policy-makers recognise that it is high time for rights-based, evidence-informed policies and programming. 7. Men Who Have Sex With Men Gay and Bisexual Men's Willingness to Receive Anal Papanicolaou Testing.
Reed AC, Reiter PL, Smith JS, Palefsky JM, Brewer NT. Am J Public Health. 2010;100:1123-9

The authors assessed the willingness of gay and bisexual men, who have high rates of anal cancer that might be prevented through regular screening, to receive anal Papanicolaou tests. They surveyed a national sample of men aged 18 to 59 years who self-identified as gay (n=236) or bisexual (n=70). Most respondents were willing to accept free screening (83%), but fewer would pay for the test (31%; McNemar's chi(2)=158.02; P<.001). Willingness to pay for screening was higher among men who reported greater worry about getting anal cancer (OR [odds ratio]=1.70; 95% confidence interval [CI]=1.06, 2.72), higher perceived likelihood of anal cancer (OR=1.88; 95% CI=1.18, 2.99), and higher income (OR=2.17; 95% CI=1.18, 3.98), in adjusted analyses. Only 33% (17 of 51) of HIV-positive respondents, who have the highest risk for anal cancer, had received anal Papanicolaou tests. Anal cancer screening was highly acceptable to gay and bisexual men, although cost was a major barrier. Efforts to reduce anal cancer disparities should target beliefs about anal cancer and barriers to anal Papanicolaou testing in this population.
For abstract access click here: http://ajph.aphapublications.org/cgi/content/abstract/100/6/1123

Editors Note: Human papilloma virus (HPV) causes most anal cancers in men who have sex with men but the HPV vaccine has not been approved for this population. Anal Pap testing (like the Papanicoloaou tests that women have for cervical cancer) annually in HIV-positive men who have sex with men and every 2 to 3

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years in HIV-negative men who have sex with men are cost-effective in the USA. With the incidence of anal cancer in men who have sex with men in the USA estimated to be up to 10 times greater than current rates of cervical cancer in women, anal Pap screening should be part of routine care in this population. This will require that physicians use gender-neutral language when talking about sexual and relationship partners, since 25% of this sample had not disclosed that they had sex with other men to their health care provider, and coverage of cost, since having to pay was reported as a significant barrier to uptake. The idea of anal Pap testing for men who have sex with men should be being discussed much more widely. 8. Co-Morbidity: HIV and Worms Prevalence and correlates of helminth co-infection in Kenyan HIV-1 infected adults.
Walson JL, Stewart BT, Sangar L, Mbogo LW, Otieno PA, Piper BK, Richardson BA, John-Stewart G. PLoS Negl Trop Dis. 2010;4:e644

Deworming HIV-1 infected individuals may delay HIV-1 disease progression. It is important to determine the prevalence and correlates of HIV-1/helminth co-infection in helminth-endemic areas. HIV-1 infected individuals (CD4>250 cells/ul) were screened for helminth infection at ten sites in Kenya. Prevalence and correlates of helminth infection were determined. A subset of individuals with soil-transmitted helminth infection was re-evaluated 12 weeks following albendazole therapy. Of 1,541 HIV-1 seropositive individuals screened, 298 (19.3%) had detectable helminth infections. Among individuals with helminth infection, hookworm species were the most prevalent (56.3%), followed by Ascaris lumbricoides (17.1%), Trichuris trichiura (8.7%), Schistosoma mansoni (7.1%), and Strongyloides stercoralis (1.3%). Infection with multiple species occurred in 9.4% of infections. After CD4 count was controlled for, rural residence (RR 1.40, 95% CI: 1.08-1.81), having no education (RR 1.57, 95% CI: 1.07-2.30), and higher CD4 count (RR 1.36, 95% CI: 1.07-1.73) remained independently associated with risk of helminth infection. Twelve weeks following treatment with albendazole, 32% of helminth-infected individuals had detectable helminths on examination. Residence, education, and CD4 count were not associated with persistent helminth infection. Among HIV-1 seropositive adults with CD4 counts above 250 cells/mm3 in Kenya, traditional risk factors for helminth infection, including rural residence and lack of education, were associated with co-infection, while lower CD4 counts were not.
For full text access click here: http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000644

Editors note: With more than 2 billion people infected with at least one helminth species worldwide, worms are not a peripheral issue. Since there is significant geographical overlap between HIV-1 and helminth infections, assessing whether people living with HIV in some settings are more likely to have helminths and evaluating the impact of helminth treatment are important endeavours. Some studies have shown decreased viral load and increased CD4+ counts following treatment of some helminths. This Kenya study found that 19% of people with HIV infection not eligible for antiretroviral treatment had helminths detected on a single stool exam, with hookworm species accounting for 56% of infections. Rural residence, higher CD4 counts, and having no education were independently associated with helminth infection, controlling for water source, sanitation, and occupation. Determining which people are more likely to be infected and what helminth is involved, repeated deworming with anti-helminthics, and education on helminth prevention can complement other interventions to delay immunosuppression in people with HIV. Association of schistosomiasis with false positive HIV test results in an African adolescent population.
Everett DB, Baisely KJ, McNerney R, Hambleton I, Chirwa T, Ross DA, Changalucha J, Watson-Jones D, Helmby H, Dunne DW, Mabey D, Hayes RJ. J Clin Microbiol. 2010; 48:1570-7

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The aim of the study was to investigate factors associated with the high rate of false positive test results observed on the 4(th) generation Murex HIV Ag/Ab Combination EIA when used in Tanzania. Clinical and socio-demographic factors associated with false positive HIV results were analysed in 6940 Tanzanian adolescents and young adults in the Northwestern region. Immunological factors, including IgG antibodies to malaria and schistosomiasis, heterophile antibody and rheumatoid factor titre, were analysed in a subsample of 284 Murex negative and 240 false positive sera. Conditional logistic regression was used to estimate odds ratios and 95% confidence intervals (CI). HIV false positive test results were associated with evidence of other infections. False positivity was strongly associated with increasing levels of Schistosoma haematobium worm IgG1, with adolescents with ODs in the top quartile at highest risk (adjusted OR=40.7, CI=8.5-194.2 compared with those in the bottom quartile). False positivity was also significantly associated with increasing S. mansoni egg IgG1, and RF titre >/= 80 (adjusted OR=8.2, CI=2.8-24.3). There was a significant negative association between Murex false positivity and levels of S. mansoni worm IgG1 and IgG2, and Plasmodium falciparum IgG1 and IgG4. In Africa, endemic infections may affect the specificity of immunoassays for HIV infection. Caution should be used when interpreting 4(th) generation HIV test results in African adolescent populations.
For abstract access click here: http://jcm.asm.org/cgi/content/abstract/48/5/1570

Editors note: Cross-reactivity between HIV-1 peptides and antibodies to Schistosoma appear to have contributed to the very high false positive HIV test results found among adolescents in this Tanzanian study. Pressure to develop highly sensitive HIV assays so that early infections are not missed has led to development of 4th generation assays that detect both HIV antigen and HIV antibody. Such tests clearly dont perform well in adolescents that are disproportionately affected by schistosomiasis. In this study, schistosomiasis IgG antibody was associated with Rheumatoid factor (RF) titres and these in turn were associated with false positive HIV test results. RF is found in autoimmune diseases such as rheumatoid arthritis but it is also associated with viral, bacterial, and other parasitic infections. Further research on the cross-reactivity of HIV diagnostic tests is warranted, with the findings used in the design and evaluation of tests specific for African populations. 9. Prevention of Mother-To- Child Transmission Effects of Highly Active Antiretroviral Therapy Duration and Regimen on Risk for Mother-to-Child Transmission of HIV in Johannesburg, South Africa.
Hoffman RM, Black V, Technau K, van der Merwe KJ, Currier J, Coovadia A, Chersich M. J Acquir Immune Defic Syndr. 2010;54:35-41

Limited information exists about effects of different antiretroviral therapy regimens and duration of regimens on mother-to-child transmission of HIV among women in Africa who start treatment for advanced immunosuppression. Between January 2004 to August 2008, 1142 women were followed at antenatal antiretroviral clinics in Johannesburg. Predictors of mother-to-child transmission (positive infant HIV DNA polymerase chain reaction at 4-6 weeks) were assessed with multivariate logistic regression. Mean age was 30.2 years (SD = 5.0) and median baseline CD4 count was 161 cells per cubic millimeter (SD = 84.3). Antiretroviral therapy duration at time of delivery was a mean 10.7 weeks (SD = 7.4) for the 85% of women who initiated treatment during pregnancy and 93.4 weeks (SD = 37.7) for those who became pregnant on antiretroviral therapy. Overall mother-to-child transmission rate was 4.9% (43 of 874), with no differences detected between antiretroviral therapy regimens. Mother-to-child transmission rates were lower in women who became pregnant on antiretroviral therapy than those initiating antiretroviral therapy during pregnancy (0.7% versus 5.7%; P = 0.01). In the latter group, each additional week of treatment reduced odds of transmission by 8% (95% confidence interval: 0.87 to 0.99, P = 0.02). Late initiation of antiretroviral therapy is associated with increased risk of mother-to-child transmission. Strategies are needed to facilitate earlier identification of HIV-infected women.

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For abstract access click here: http://journals.lww.com/jaids/pages/articleviewer.aspx?year=2010&issue=05010&article=00005&type=abs tract

Editors note: Viral suppression typically occurs after 10-16 weeks of antiretroviral therapy and this likely explains the strong association found in this study between duration of antiretroviral treatment and HIV transmission to infants, with each additional week of treatment reducing the risk of HIV transmission. Thus it is no surprise that women who were on antiretroviral treatment when they became pregnant were significantly less likely to transmit HIV to their infants than women who were identified as treatment-eligible during pregnancy. In fact, there were no transmissions among women who were on antiretroviral treatment for more than 32 weeks before delivery. What is surprising is that pregnancy was planned in only 28.6% of women who became pregnant on treatment and 31.4% of those who started treatment during pregnancy. Since all of these women knew their HIV status, better integration of family planning services with HIV services could help avoid unplanned pregnancy and reduce infant infections even further. Restricted genetic diversity of HIV-1 subtype C envelope glycoprotein from perinatally infected Zambian infants.
Zhang H, Tully DC, Hoffmann FG, He J, Kankasa C, Wood C. PLoS One. 2010;5:e9294

Mother-to-child transmission of HIV-1 remains a significant problem in the resource-constrained settings where anti-retroviral therapy is still not widely available. Understanding the earliest events during HIV-1 transmission and characterizing the newly transmitted or founder virus is central to intervention efforts. In this study, the authors analyzed the viral env quasispecies of six mother-infant transmission pairs and characterized the genetic features of envelope glycoprotein that could influence HIV-1 subtype C perinatal transmission. The V1-V5 region of env was amplified from 6 mother-infant transmission pairs baseline samples and 334 DNA sequences in total were analyzed. A comparison of the viral population derived from the mother and infant revealed a severe genetic bottleneck occurring during perinatal transmission, which was characterized by low sequence diversity in the infant. Phylogenetic analysis indicates that most likely in all their infant subjects a single founder virus was responsible for establishing infection. Furthermore, the newly transmitted viruses from the infant had significantly fewer potential Nlinked glycosylation sites in Env V1-V5 region and showed a propensity to encode shorter variable loops compared to the nontransmitted viruses. In addition, a similar intensity of selection was seen between mothers and infants with a higher rate of synonymous (dS) compared to nonsynonymous (dN) substitutions evident (dN/dS<1). These results indicate that a strong genetic bottleneck occurs during perinatal transmission of HIV-1 subtype C. This is evident through population diversity and phylogenetic patterns where a single viral variant appears to be responsible for infection in the infants. As a result the newly transmitted viruses are less diverse and harbored significantly less glycosylated envelope. This suggests that viruses with the restricted glycosylation in envelope glycoprotein appeared to be preferentially transmitted during HIV-1 subtype C perinatal transmission. In addition, their findings also indicated that purifying selection appears to predominate in shaping the early intrahost evolution of HIV-1 subtype C envelope sequences.
For full text access click here: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0009294

Editors note: All six infants in this study were negative for HIV at birth by PCR (polymerase chain reaction) and viral isolation, suggesting that transmission occurred during delivery or breastfeeding. They all had passively acquired maternal antibody, which may have imposed a selection pressure on the transmitted virus. The low amount of maternal virus they were exposed to through breastfeeding may also have contributed to the genetic bottleneck documented here. Although the mothers had a variety of viral quasispecies, only a single founder virus was transmitted. However, that virus had low sequence diversity,

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restricted glycosylation in the Env V1-V5 region, and a higher replicative fitness suggesting that it was better able to establish efficient replication in its new host. Four of these infants were fast progressors, dying before the age of 1 year. Studies such as this one characterising newly transmitted or founder viruses can help inform new interventions to prevent mother-to-child transmission. 10. Human Rights Access to pain treatment as a human right.
Lohman D, Schleifer R, Amon JJ. BMC Med. 2010;8:8.

Almost five decades ago, governments around the world adopted the 1961 Single Convention on Narcotic Drugs which, in addition to addressing the control of illicit narcotics, obligated countries to work towards universal access to the narcotic drugs necessary to alleviate pain and suffering. Yet, despite the existence of inexpensive and effective pain relief medicines, tens of millions of people around the world continue to suffer from moderate to severe pain each year without treatment. Significant barriers to effective pain treatment include: the failure of many governments to put in place functioning drug supply systems; the failure to enact policies on pain treatment and palliative care; poor training of healthcare workers; the existence of unnecessarily restrictive drug control regulations and practices; fear among healthcare workers of legal sanctions for legitimate medical practice; and the inflated cost of pain treatment. These barriers can be understood not only as a failure to provide essential medicines and relieve suffering but also as human rights abuses. According to international human rights law, countries have to provide pain treatment medications as part of their core obligations under the right to health; failure to take reasonable steps to ensure that people who suffer pain have access to adequate pain treatment may result in the violation of the obligation to protect against cruel, inhuman and degrading treatment.
For full text access click here: http://www.biomedcentral.com/1741-7015/8/8

Editors note: Low- and middle-income countries are home to half of all cancer patients and more than 90% of HIV infections, yet they consume only 6% of the morphine used worldwide. Although the International Narcotics Control Board, which monitors the implementation of the UN drug conventions, drew attention in 1995 to the dual drug control obligation to ensure adequate availability of narcotic drugs, including opiates, for medical and scientific purposes, while preventing illicit production, trafficking, and use of such drugs, an estimated 80% of the worlds population has either no access or insufficient access to treatment for moderate to severe pain. Chronic pain, a common symptom of both cancer and HIV disease, has a profound impact on the quality of life, reduces treatment adherence, and influences the course of disease it is one of the most significant causes of suffering and disability worldwide. Overcoming a vicious cycle of under-treatment requires governments to develop pain management and palliative care policies, reform regulations that impede access, institute health care worker training, and ensure affordability, including through investigating the feasibility of local manufacture. 11. Treatment First-year lymphocyte T CD4+ response to antiretroviral therapy according to the HIV type in the IeDEA West Africa collaboration.
Drylewicz J, Eholie S, Maiga M, Zannou DM, Sow PS, Ekouevi DK, Peterson K,Bissagnene E, Dabis F, Thibaut R; International epidemiologic Databases to Evaluate AIDS (IeDEA) West Africa Collaboration. AIDS. 2010 24:1043-50

The objective of the study was to compare the lymphocyte T CD4+ (CD4) response to combinations of antiretroviral therapy in HIV-1, HIV-2 and dually positive patients in West Africa. The study was a collaboration of 12 prospective cohorts of HIV-infected adults followed in Senegal (2), Gambia (1), Mali UNAIDS_CSA-RO_HIVthisweek_82_100621

(2), Benin (1) and Cte d'Ivoire (6). Nine thousand, four hundred and eighty-two patients infected by HIV-1 only, 270 by HIV-2 only and 321 dually positive, who initiated an antiretroviral therapy. CD4 change over a 12-month period. Observed CD4 cell counts at treatment initiation were similar in the three groups [overall median 155, interquartile range (IQR) 68; 249 cells/microl). In HIV-1 patients, the most common antiretroviral therapy regimen was two nucleoside reverse transcriptase inhibitors and one non-nucleoside reverse transcriptase inhibitor (N = 7714) as well as for dually positive patients (N = 135). HIV-2 patients were most often treated with a protease inhibitor-based regimen (N = 193) but 45 of them were treated with an non-nucleoside reverse transcriptase inhibitor-containing antiretroviral therapy. In those treated with a non-nucleoside reverse transcriptase inhibitor-containing regimen, the estimated mean CD4 change between 3 and 12 months was significantly lower in HIV-2 (-41 cells/microl per year) and dually positive patients (+12 cells/microl per year) compared to HIV-1 patients (+69 cells/microl per year, overall P value 0.01). The response in HIV-2 and dually positive patients treated by another regimen (triple nucleoside reverse transcriptase or protease inhibitor-containing antiretroviral therapy) was not significantly different than the response obtained in HIV-1-only patients (all P values >0.30). An optimal CD4 response to antiretroviral therapy in West Africa requires determining HIV type prior to initiation of antiretroviral drugs. Non-nucleoside reverse transcriptase inhibitors are the mainstay of first-line antiretroviral therapy in West Africa but are not adapted to the treatment of HIV-2 and dually positive patients.
For abstract access click here: http://journals.lww.com/aidsonline/pages/articleviewer.aspx?year=2010&issue=04240&article=00014&typ e=abstract

Editors note: Non-nucleoside reverse transcriptase inhibitors (NNRTI) are part of first-line regimens in West Africa, the epicenter of the HIV-2 epidemic, but are inappropriate for treatment of HIV-2 infection. Although HIV-2 infection has a longer symptom-free period, lower viral load, and slower disease progression, it can lead to AIDS. This observational study of more than 9000 patients in West Africa found poor CD4+ responses to treatment in patients with HIV-2 infection placed on NNRTI but comparable responses to treatment in people with HIV-2 infection, dual infections, and HIV-1 infection placed on protease inhibitor-containing regimens. This points to the need for medical training, appropriate medications, and diagnostic protocols at clinic level but also underscores the rationale for randomized controlled trials to determine the best drug regimens for patients with HIV-2 infection. Measures of site resourcing predict virologic suppression, immunologic response and HIV disease progression following highly active antiretroviral therapy (HAART) in the TREAT Asia HIV Observational Database (TAHOD).
Oyomopito R, Lee MP, Phanuphak P, Lim PL, Ditangco R, Zhou J, Sirisanthana T, Chen YM, Pujari S, Kumarasamy N, Sungkanuparph S, Lee CK, Kamarulzaman A, Oka S, Zhang FJ, Mean CV, Merati T, Tau G, Smith J, Li PC; on behalf of The TREAT Asia HIV Observational Database. HIV Med. 2010. [Epub ahead of print]

Surrogate markers of HIV disease progression are HIV RNA in plasma viral load and CD4 cell count (immune function). Despite improved international access to antiretrovirals, surrogate marker diagnostics are not routinely available in resource-limited settings. Therefore, the objective was to assess effects of economic and diagnostic resourcing on patient treatment outcomes. Analyses were based on 2333 patients initiating antiretroviral therapy from 2000 onwards. Sites were categorized by World Bank country income criteria (high/low) and annual frequency of plasma viral load (>/=3, 1-2 or <1) or CD4 (>/=3 or <3) testing. Endpoints were time to AIDS/death and change in CD4 cell count and plasma viral load suppression (<400 HIV-1 RNA copies/mL) at 12 months. Demographics, Centers for Disease Control and Prevention (CDC) classification, baseline plasma viral load /CD4 cell counts, hepatitis B/C coinfections and antiretroviral therapy regimen were covariates. Time to AIDS/death was analysed by proportional hazards models. CD4 and plasma viral load endpoints were analysed using linear and logistic regression, respectively. Increased disease progression was associated with site-reported plasma viral load UNAIDS_CSA-RO_HIVthisweek_82_100621

testing less than once per year [hazard ratio (HR)=1.4; P=0.032], severely symptomatic HIV infection (HR=1.4; P=0.003) and hepatitis C virus coinfection (HR=1.8; P=0.011). A total of 1120 patients (48.2%) had change in CD4 cell count data. Smaller increases were associated with older age (P<0.001) and 'Other' HIV source exposures, including injecting drug use and blood products (P=0.043). A total of 785 patients (33.7%) contributed to the plasma viral load suppression analyses. Patients from sites with plasma viral load testing less than once per year [odds ratio (OR)=0.30; P<0.001] and reporting 'Other' HIV exposures experienced reduced suppression (OR=0.28; P<0.001). Low measures of site resourcing were associated with less favourable patient outcomes, including a 35% increase in disease progression in patients from sites with plasma viral load testing less than once per year.
For abstract access click here: http://www3.interscience.wiley.com/journal/123326392/abstract

Editors note: Setting out to determine the extent to which clinical resourcing affected patient outcomes in 17 clinical sites in Asia, this observational study followed 2333 patients. An increased risk of disease progression was found for patients at sites reporting that viral load testing was performed less than once a year, with a 35% increased risk of developing AIDS or dying. Rather than using viral load testing to monitor treatment efficacy, it is possible that, in the face of resource constraints, clinics were using viral load testing to confirm treatment failure. Lack of viral load testing increases the likelihood that patients will be maintained on failing regimens and develop highly resistant HIV. Expanding access to viral load testing and developing cheaper viral load tests that can be used more frequently to monitor treatment outcomes is an urgent global priority as access to antiretroviral therapy continues to expand. 12. Orphans and HIV Increased risk of HIV-infection among school-attending orphans in rural Zimbabwe.
Pascoe SJ, Langhaug LF, Durawo J, Woelk G, Ferrand R, Jaffar S, Hayes R, Cowan FM. AIDS Care. 2010;22:206-20

In Zimbabwe around 1.1 million children have been orphaned due to AIDS. The authors conducted a survey among school-attending youth in rural south-eastern Zimbabwe in 2003, and examined the association between orphaning and risk of HIV. They enrolled 30 communities in three provinces. All students attending Year 2 of secondary school were eligible. Each completed a questionnaire and provided a finger-prick blood specimen for testing for HIV-1 and HSV-2 antibodies. Female participants were tested for pregnancy. Six thousand seven hundred and ninety-one participants were recruited (87% of eligible); 35% had lost one or both parents (20% of participants had lost their father; 6% their mother; and 9% both parents). Orphans were not poorer than non-orphans based on reported access to income, household structure and ownership of assets. There was strong evidence that orphans, and particularly those who had lost both parents, were at increased sexual risk, being more likely to have experienced early sexual debut; to have been forced to have sex; and less likely to have used condoms. Fifty-one students were HIV positive (0.75%). Orphans were three times more likely to be HIV infected than non-orphans (adjusted odds ratio = 3.4; 95% confidence interval: 1.8-6.6). Over 60% of those HIV positive were orphaned. Among school-going youth, the rates of orphaning were very high; there was a strong association between orphaning and increased risk of HIV, and evidence of greater sexual risk taking among orphans. It is essential that we understand the mechanisms by which orphaned children are at increased risk of HIV in order to target prevention and support appropriately.
For full text access click here: http://www.informaworld.com/smpp/section?content=a918857901&fulltext=713240928

Editors note: The Zimbabwe Demographic Health Survey of 2005-2006 estimated that 36% of children aged 15-17 years were orphaned, with rural young people in this age group more likely to be orphans than urban youth. This study of 6791 school-going adolescents found 35% had lost one or both parents. Although

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HIV prevalence was below 1%, almost two-thirds of those identified as HIV-positive were orphans. Male orphans were at almost three times greater risk of being infected and female orphans at more than four times greater risk of HIV infection than their non-orphan counterparts. Some of these orphans may have been infected vertically at birth or through breastfeeding but this is unlikely as half had lost only their fathers, the chance of surviving to age 15 in the absence of treatment is low, and there was increased reporting of sexual risk taking by orphans. Although the safety net of the extended family continues to shelter increasing numbers of orphans, programmes to reduce HIV-related risks among these young people are needed now and will be increasingly important as the epidemic continues to deepen. That was HIV this week, signing off.

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Editors notes on journal access

For readers in all countries: All abstracts in HIV This Week are freely available on the Web. You can access many scientific journals free of charge no matter where you are located, but for some journals you do need a subscription to access the full text of an article. Other journals offer free access to full-text articles after a certain period of time - see lists at Pubmed Central (click here) (and High Wire Press (click here). A number of journals are free to readers in all countries through ScienceDirect (click here). Examples of open access journals are BioMed Central journals (click here) and Public Library of Science (PLoS) journals (click here). Open Science Directory (click here) is a global search tool open access journals and journals in special programmes for developing countries. For residents of low- and middle-income countries: The Health InterNetwork Access to Research Initiative (HINARI), set up by the World Health Organisation (WHO) together with major publishers, enables readers at health institutions in low- and middle-income countries to gain access to one of the world's largest collections of biomedical and health literature. Over 6200 journal titles are now available to health institutions in 108 countries, benefiting many thousands of health workers and researchers, and in turn, contributing to improved world health. More information on the HINARI programme and eligible countries is available at their website (click here). Local, not-for-profit institutions in low- and middle- income countries may register for access to the journals through HINARI. Institutions in countries with GNP per capita below $1250 are eligible for free access. Institutions in countries with GNP per capita $1250-$3000 pay a fee of $1000 per year/institution. There is also free access to journals published online with the assistance of HighWire Press. This link: Clicking here will automatically detect if your internet connection is from a developing country and give you free access to their journals. For employees of UNAIDS or WHO: If you work for WHO or UNAIDS in Geneva, you can access a number of journals available from the WHO library by going to the WHO intranet (click here). If you work for UNAIDS outside Geneva you can access the WHO intranet through the following link: remote. When you have entered your UNAIDS username and password, click on intranet WHO. On the WHO intranet homepage, click on information resources WHO library online information resources online journals (GIFT) - A to Z list and you will see the list of accessible journals.

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