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ACTHIV 2016 ~ Recap
The document provides a recap of the ACTHIV 2016 conference held in Dallas, Texas. It summarizes several topics that were covered at the conference, including updates to the National HIV/AIDS Strategy, new models of HIV care under the Affordable Care Act, improved HIV and hepatitis testing, managing HIV patients who use substances or are transgender, and updates on pre-exposure prophylaxis (PrEP) use. The conference provided an overview of current issues in HIV care and new strategies for managing patients and the future of HIV.
ACTHIV 2016 ~ Recap
- 1. ACTHIV 2016 ~Recap Roosevelt Bell HIV Medical Case Manager ~ The Sulzbacher Center COMPLETE OVERVIEW OF ACTHIV CONFERENCE 2016 ~ DALLAS TEXAS
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- 3. National HIV/AIDS Strategyfor the United States Updated to 2020
- 4. HIV Care inACA Era
- 5. New Models ToConsider
- 6. HIV ~ HepatitisTesting
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- 13. Managing HIV TheFuture
- 14. References: Overview ofACTHIV ~ 2016 Convention Dallas, Texas Attendee ~ Roosevelt Bell HIV Medical Case Manager ~ The Sulzbacher Center
Editor's Notes
- #3 Acquired immunodeficiency syndrome (AIDS) was first recognized as a new disease in the United States when clinicians in New York, Los Angeles, and San Francisco began to see young, homosexual men with Pneumocystis carinii (now P jiroveci) pneumonia (PCP) and Kaposi's sarcoma (KS), unusual diseases for young adults not known to be immunosuppressed. The first report in the medical literature that alerted the world to this new immunodeficiency syndrome appeared in June of 1981 and described five young, homosexual men in Los Angeles with PCP.(1) That observation was followed a few weeks later by a report of 26 homosexual men, from both New York and San Francisco, with KS (four of whom also had PCP).(2) Other reports followed of a similar syndrome in injecting drug users.(3) All of these individuals shared a profound immunodeficiency, the hallmark of which was a depletion of CD4-positive, or T-helper, lymphocytes. In mid-1982, the Centers for Disease Control and Prevention (CDC) published a report of 34 cases of KS and opportunistic infections (OIs) in Haitians living in several different states in the United States, none of whom reported homosexual behavior.(4) One week later, the CDC reported on PCP among persons with hemophilia.(5) The first case in a transfusion recipient was reported from San Francisco in an infant in late 1982. For a short time, the new disease was called gay-related immunodeficiency syndrome (GRIDS), but by September of 1982, the CDC had published a case definition, using the current designation of acquired immune deficiency syndrome (AIDS) in print, and it was rapidly adopted by researchers.(6) The prominence of homosexual men and injecting drug users in the early cases of AIDS suggested an agent that was both blood borne and sexually transmitted, although early speculation about the etiology of AIDS included the hypothesis that all the patients were immunosuppressed because they had a history of drug use or multiple sexually transmitted diseases or malnutrition (the "immune overload" hypothesis).(7) The majority of researchers thought that the likely agent was a sexually transmitted virus that would be found in the peripheral blood. HIV was first isolated in France in 1983 by Françoise Barré-Sinoussi in the laboratory of Luc Montaignier as lymphadenopathy-associated virus (LAV),(8) but strong evidence that it was the AIDS virus did not appear until 1984, when four papers were published in one issue of Science by Robert Gallo and colleagues, who designated their isolate HTLV-III.(9) The virus was also isolated in San Francisco in 1984 by Jay Levy, who published his findings a few months later in 1984 and named his isolate AIDS-associated retrovirus (ARV).(10) All three of these designations for the virus appear in the early literature. The International Committee on the Taxonomy of Viruses chose the designation human immunodeficiency virus (HIV) in 1986. With the discovery by Montaignier's group in late 1986 of the related HIV-2 virus in West Africa, the original virus became HIV-1.(11) This report updates and consolidates all previous U.S. Public Health Service recommendations for the management of health-care personnel (HCP) who have occupational exposure to blood and other body fluids that might contain hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV). Recommendations for HBV postexposure management include initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure. Postexposure prophylaxis (PEP) with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine-response status of the exposed person. Guidance is provided to clinicians and exposed HCP for selecting the appropriate HBV PEP. Immune globulin and antiviral agents (e.g., interferon with or without ribavirin) are not recommended for PEP of hepatitis C. For HCV postexposure management, the HCV status of the source and the exposed person should be determined, and for HCP exposed to an HCV positive source, follow-up HCV testing should be performed to determine if infection develops. Recommendations for HIV PEP include a basic 4-week regimen of two drugs (zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] and d4T) for most HIV exposures and an expanded regimen that includes the addition of a third drug for HIV exposures that pose an increased risk for transmission. When the source person's virus is known or suspected to be resistant to one or more of the drugs considered for the PEP regimen, the selection of drugs to which the source person's virus is unlikely to be resistant is recommended. In addition, this report outlines several special circumstances (e.g., delayed exposure report, unknown source person, pregnancy in the exposed person, resistance of the source virus to antiretroviral agents, or toxicity of the PEP regimen) when consultation with local experts and/or the National Clinicians' Post-Exposure Prophylaxis Hotline ([PEPline] 1-888-448-4911) is advised. Occupational exposures should be considered urgent medical concerns to ensure timely postexposure management and administration of HBIG, hepatitis B vaccine, and/or HIV PEP. The lentivirus human immunodeficiency virus (HIV) causes AIDS by interacting with a large number of different cells in the body and escaping the host immune response against it. HIV is transmitted primarily through blood and genital fluids and to newborn infants from infected mothers. The steps occurring in infection involve an interaction of HIV not only with the CD4 molecule on cells but also with other cellular receptors recently identified. Virus-cell fusion and HIV entry subsequently take place. Following virus infection, a variety of intracellular mechanisms determine the relative expression of viral regulatory and accessory genes leading to productive or latent infection. With CD4+ lymphocytes, HIV replication can cause syncytium formation and cell death; with other cells, such as macrophages, persistent infection can occur, creating reservoirs for the virus in many cells and tissues. HIV strains are highly heterogeneous, and certain biologic and serologic properties determined by specific genetic sequences can be linked to pathogenic pathways and resistance to the immune response. The host reaction against HIV, through neutralizing antibodies and particularly through strong cellular immune responses, can keep the virus suppressed for many years. Long-term survival appears to involve infection with a relatively low-virulence strain that remains sensitive to the immune response, particularly to control by CD8+ cell antiviral activity. Several therapeutic approaches have been attempted, and others are under investigation. Vaccine development has provided some encouraging results, but the observations indicate the major challenge of preventing infection by HIV. Ongoing research is necessary to find a solution to this devastating worldwide epidemic.
- #4 Patient retention in the HIV Community could easily be thought of as the lifeblood of any successful medical practice. In fact, it’s of such tremendous value, that the benefits to both patient and practice are readily seen. A medical office that keeps its patients coming back through the door realizes increased revenue, a rise in referrals, and, ultimately, the survival and long-term success of the practice as a business. On the other hand, the patient is able to reap the benefits of a long lasting relationship with their provider as well as the myriad of gains attributable to continuity of care. The question then quickly becomes, just how does one keep patients coming back through the door time and again? As with any good, and therefore successful, business, there are a number of individual behaviors and attitudes that combine to contribute to an overall increase in patient retention. •Be Genuine. A patient’s belief in the value of their own health and the steps that they need to implement in order to realize that health starts with your own belief and confidence. In a culture inundated with chains of superstore giants and their false customer service, people can spot a fake smile and insincere “how are you today?” a mile away. Particularly in health care, it’s vital that patients believe that their provider genuinely cares for them and their wellbeing. When they walk out of your doors, let it be with full confidence that you have a vested interest in their welfare. What they believe is what they will then share with others (you guessed it, referrals!). •Education. An educated patient is a valuable patient. There’s a reason why psychiatrists in training frequently undergo treatment themselves. It helps to educate them in the value of their own practice. Taking the time to educate your patients will likewise help them to see the value of their health care and ensure that they continue to turn to you for guidance. A starting point for any medical practice could even include a structured or planned educational program for their patients. •Finances. Let’s face it, third party pay is confusing for just about anyone, and financial problems can be embarrassing for many patients especially for the population we serve. By providing personalized assistance with understanding and making their financial obligations, you set yourself as a reliable and comforting source of help. In other words, you make it easy for them to return. •Family. Everyone likes to feel as if they belong to something, whether it’s a family, community, or circle of friends. Some practices have gotten creative with the labels we use, referring to patients as “practice members”, partaking in “wellness clubs”, and giving their opinions through “advisory committees”. The point is to make them feel special and a part of something that they’ll want to return to over and over again. • ART: Measure, review, and improve. Commit your entire organization to a process of continual quality improvement on a daily basis. Set goals, measure your progress, address problems before they get big. Find something to improve every day. By never stagnating in “the way we’ve always done it”, have the courage to shake things up, always with the ultimate goals of patient wellness, satisfaction, and retention. A successful business sees any given customer not as a single transaction, but as a lifetime partner. A successful medical practice will take the same view of their patients. There’s really no secret to keeping patients coming back. It does, however, take an investment in time, attention, and the willingness to implement a few simple changes.
- #5 Currently, fewer than one in five (17%) people living with HIV has private insurance and nearly 30% do not have any coverage. Medicaid, the Federal-state program that provides health care benefits to people with low incomes and those living with disabilities, is a major source of coverage for people living with HIV/AIDS, as is Medicare, the Federal program for seniors and people with disabilities. The Ryan White HIV/AIDS Program is another key source of funding for health and social services for this population. The Affordable Care Act is one of the most important pieces of legislation in the fight against HIV/AIDS in our history. As of September 23, 2010, insurers are no longer able to deny coverage to children living with HIV or AIDS. The parents of as many as 17.6 million children with pre-existing conditions no longer have to worry that their children will be denied coverage because of a pre-existing condition. Insurers also are prohibited from cancelling or rescinding coverage to adults or children because of a mistake on an application. And insurers can no longer impose lifetime caps on insurance benefits. Because of the law, 105 million Americans no longer have a lifetime dollar limit on essential health benefits. These changes will begin to improve access to insurance for people living with HIV/AIDS and other disabling conditions and help people with these conditions retain the coverage they have. For people who have been locked out of the insurance market because of their health status, including those living with HIV/AIDS, the law created the Pre-existing Condition Insurance Plan. More than 90,000 people—some of whom are living with HIV or AIDS—have enrolled in this program, which has helped change lives and, in many cases, save them. These changes will provide an important bridge to the significant changes in 2014 as the Affordable Care Act is fully implemented. Beginning in 2014, insurers will not be allowed to deny coverage to anyone or impose annual limits on coverage. People with low and middle incomes will be eligible for tax subsidies that will help them buy coverage from new state health insurance Exchanges. The Affordable Care Act also broadens Medicaid eligibility to generally include individuals with income below 133% of the Federal poverty line ($14,400 for an individual and $29,300 for a family of 4), including single adults without children who were previously not generally eligible for Medicaid. As a result, in many states, a person living with HIV who meets this income threshold will no longer have to wait for an AIDS diagnosis in order to become eligible for Medicaid. The Affordable Care Act also closes, over time, the Medicare Part D prescription drug benefit "donut hole," giving Medicare enrollees living with HIV and AIDS the peace of mind that they will be better able to afford their medications. Beneficiaries receive a 50% discount on covered brand-name drugs while they are in the "donut hole," a considerable savings for people taking costly HIV/AIDS drugs. And in the years to come, they can expect additional savings on their prescription drugs while they are in the coverage gap until it is closed in 2020. In addition, as a result of the health care law, AIDS Drug Assistance Program (ADAP) benefits are now considered as contributions toward Medicare Part D's True Out of Pocket Spending Limit ("TrOOP"). This is a huge relief for ADAP clients who are Medicare Part D enrollees, since they will now be able to move through the donut hole more quickly, which was difficult, if not impossible, for ADAP clients to do before this change.
- #6 Harm Reduction Approach: Consider the impact that substance use has on client’s ability to adhere. Compliance is the Key: Know the difference between Compliance and Adherence. Begin to use integrated models. PACT Model: Patient Aligned Care Team Phone Clinic; Incorporation of the Phone, Text Model. Reaching clients where they are, and using the methods that works for them. PAN Model: Patient Assistant Network
- #7 New RNA Rapid Test CDC will be rolling this out within the next several Months. More Hep C Testing: Guidelines and Procedures ( HCVGuidelines.org) Grants that focus on Special Needs: (SPNS) Special Projects of National Significance (Website) All Staff should be trained in HIV Prevention and Intervention! Hepatitis is broad term referring to inflammation of the liver. This condition is most often caused by a virus. In the United States, the most common causes of viral hepatitis are hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV). HBV and HCV are common among people who are at risk for, or living with, HIV. You can get some forms of viral hepatitis the same way you get HIV—through unprotected sexual contact and injection drug use. In fact, about 80% of HIV-infected injection drug users in the U.S. are also infected with HCV. HCV infection sometimes results in an acute illness, but most often becomes a chronic condition that can lead to cirrhosis of the liver and liver cancer. HCV infection is more serious in people living with HIV because it leads to liver damage more quickly. Co-infection with HCV may also affect the treatment of HIV infection. Therefore, it’s important for people who inject drugs to know whether they are also infected with HCV and, if they aren’t, to take steps to prevent infection. To find out if you are infected with HCV, ask your doctor or other healthcare provider to test your blood. HCV can be treated successfully, even in people who have HIV. Hepatitis is broad term referring to inflammation of the liver. This condition is most often caused by a virus. In the United States, the most common causes of viral hepatitis are hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV). HBV and HCV are common among people who are at risk for, or living with, HIV. You can get some forms of viral hepatitis the same way you get HIV—through unprotected sexual contact and injection drug use. In fact, about 80% of HIV-infected injection drug users in the U.S. are also infected with HCV. HCV infection sometimes results in an acute illness, but most often becomes a chronic condition that can lead to cirrhosis of the liver and liver cancer. HCV infection is more serious in people living with HIV because it leads to liver damage more quickly. Co-infection with HCV may also affect the treatment of HIV infection. Therefore, it’s important for people who inject drugs to know whether they are also infected with HCV and, if they aren’t, to take steps to prevent infection. To find out if you are infected with HCV, ask your doctor or other healthcare provider to test your blood. HCV can be treated successfully, even in people who have HIV.
- #8 Alcohol and other drug use can play a significant role in the spread of HIV. For example: •Injection drug use is one of the causes of HIV in the United States and is responsible for approximately 10% of HIV cases annually. •If you inject drugs, you can get HIV from sharing drug preparation or injecting equipment (“works”) with a person who has HIV. You can also then pass HIV to your sex and drug-using partners. •Drinking alcohol or taking other drugs can increase your risk for HIV and other sexually transmitted diseases (STDs). Being drunk or high affects your ability to make safe choices and lowers your inhibitions, leading you to take risks you are less likely to take when sober, such as having sex without a condom or sex with multiple partners. •Transactional sex (trading sex for drugs or money) can also increase your risk for getting HIV. •If you use drugs, you at are a higher risk for HIV infection and therefore should seek HIV testing. Use the HIV/AIDS Prevention and Services Locator to find a HIV testing site near you. •If you already have HIV, drinking alcohol or taking other drugs can affect your immune system and may speed up the progression of the disease. Drinking or taking drugs also can affect your HIV treatment adherence. Your mental health is just as important as your physical health. When you have positive mental health, you generally are able to: function better at work, at school, and in relationships. cope more effectively with life’s difficulties, such as the death of a loved one, ending a relationship, job stress, health issues, and family or financial problems. take better care of yourself physically. provide better care for your children or other family members. But mental health problems can affect the way you think, feel, and behave, and can change how well you function at work and at home. If you are living with HIV, mental health problems can affect your physical health by: making it harder for you to take all your HIV medicines on time. making it harder for you to keep your health appointments or take advantage of your support network. interfering with your healthy behaviors, such as getting enough sleep and exercise and avoiding risk behaviors such as having unprotected sex. impairing your ability to cope with the stresses of daily life. Mental health problems are very common among all Americans, not just those living with HIV. In fact, in 2012, about: One in five American adults experienced a diagnosable mental illness. Nearly one in 10 young people experienced a period of major depression. Four percent of American adults lived with a serious mental illness, such as schizophrenia, bipolar disorder, or major depression. As a person living with HIV, it is important for you to be aware that you have an increased risk for developing mood, anxiety, and cognitive disorders. These conditions are treatable. People who experience mental health problems can get better and many recover completely. You can better manage your overall health and well-being if you know how having HIV can affect your mental health and what resources are available to help you if you need it.
- #11 Looking for basic facts about PrEP and PEP—and the difference between the two? Start here for some simple and straightforward definitions of key terms that come up frequently when talking about PrEP and PEP, as well as a run-down of the science behind PrEP and a few things to know about this new HIV prevention tool. Key Terms PrEP: Short for “pre-exposure prophylaxis,” PrEP is an HIV prevention strategy in which HIV-negative people take an oral pill once a day before coming into contact with HIV to reduce their risk of HIV infection. PrEP must be taken for at least 7 days to reach optimal levels of protection against HIV. PEP: Short for “post-exposure prophylaxis,” PEP is an HIV prevention strategy in which HIV-negative people take anti-HIV medications after coming into contact with HIV to reduce their risk of HIV infection. PEP must be started within 72 hours after HIV exposure. Condoms: A type of barrier used during sex. “Male” condoms are worn over the penis, and “female” condoms can be worn inside the vagina or rectum. Condoms are the only tool that protects against both HIV, certain sexually transmitted infections (STIs), and pregnancy when used correctly and consistently. Truvada: This brand-name drug combines tenofovir (Viread) and emtricitabine (Emtriva) into one pill and is made by Gilead Sciences. It has been used by HIV-positive people to treat HIV disease since 2004, and currently is the only pill approved for PrEP for HIV-negative people. Adherence: The degree to which an individual takes a medication regularly as prescribed. For HIV-negative people, not taking PrEP daily can lead to increased risk for HIV infection. (Check out these tried-and-true tips and resources to boost adherence.) HIV antibody test: A type of HIV test that checks a blood or oral fluid sample for antibodies against HIV. Because the body does not begin producing antibodies for two weeks or longer, an antibody test will not reliably detect a recent (acute) HIV infection. Several community-based clinics offer HIV antibody tests that offer results the same day. HIV RNA test: Different from an antibody HIV test, this test looks for the presence of the actual virus in the blood and can detect if someone has acute HIV infection. In order to determine if someone is eligible for PrEP, a medical provider must confirm the individual is actually HIV negative. There are currently no HIV RNA tests approved by the FDA that offer same-day results. Clinical trial: A medical study to determine whether a new drug or drug combination, assay, device, or procedure is safe and/or effective. To learn more about the clinical trial process and different clinical trial. Placebo: To help determine whether a new drug or tool is effective, participants in a clinical trial will be assigned to take either the drug or tool being studied or a placebo, which contains no drug. For example, in studies of oral PrEP, the placebo was a sugar pill. The group of participants who receive the placebo is the “control arm” of the study. Demonstration project: After a drug has been deemed safe and effective through clinical trials, a demonstration project is meant to figure out how to best deliver and use the new drug or tool in a real-world setting. Bone mineral density: A measure of how much calcium and other minerals are present in bone tissue. With Truvada for PrEP, 1 in 100 people will experience decreasing bone mineral density issues, which go away once drug is stopped. Creatinine clearance: An indicator of kidney health that is monitored by medical providers for individuals taking PrEP. With Truvada for PrEP, 1 in 200 people will have kidney problems with mild increases in serum creatinine, which go away once the drug is stopped. Things to Keep in Mind Only people who are HIV negative should use PrEP or PEP. You must be tested for HIV and have a documented negative test result before starting PrEP. PrEP and PEP are available by prescription from a medical provider, such as a physician, nurse practitioner, or physician assistant. You can also get PEP at your local emergency room or urgent care clinic, although these locations may provide just the first two or three days’ doses to get you started (for example, until your medical provider’s office reopens on a weekday). You will need to talk with your provider to see if PrEP or PEP is right for you. PrEP is more than just taking a pill every day; it also involves frequent medical visits and lab tests to check for HIV, other STIs, and any changes in kidney health. Neither PrEP nor PEP protects against other STIs or pregnancy, and they are not cures for HIV. PEP is taken for 28 days. PrEP does not have to be taken forever and can be stopped at any time under the supervision of your medical provider. When stopping PrEP, individuals should continue using it for four weeks after the last significant exposure. If you’ve used PEP in the last year, it might be a good idea to talk to your medical provider about PrEP. Curious about how to access PrEP or PEP in your community? Most private health insurance plans, as well as Medicaid, cover the cost of Truvada for PrEP. If you have specific questions. A question that often comes up when talking about PrEP is “What about condoms?” For people who do not use condoms every time they have sex, PrEP provides an effective layer of protection against HIV. The choice to use PrEP, like the choice to use condoms, is a personal decision. The important thing is to find an HIV prevention strategy that fits your needs and meets your sexual health goals.
- #12 Although clinical experience and preliminary research suggest that some transgender people are at significant risk for HIV, this stigmatized group has so far been largely ignored in HIV prevention. As part of the development of HIV prevention education targeting the transgender population, focus groups of selected transgender individuals assessed their HIV risks and prevention needs. Data were gathered in the following four areas: (1) the impact of HIV/AIDS on transgender persons; (2) risk factors; (3) information and services needed; and (4) recruitment strategies. Findings indicated that HIV/AIDS compounds stigmatization related to transgender identity, interferes with sexual experimentation during the transgender 'coming out' process, and may interfere with obtaining sex reassignment. Identified transgender-specific risk factors include: sexual identity conflict, shame and isolation, secrecy, search for affirmation, compulsive sexual behaviour, prostitution, and sharing needles while injecting hormones. Community involvement, peer education and affirmation of transgender identity were stressed as integral components of a successful intervention. Education of health professionals about transgender identity and sexuality and support groups for transgender people with HIV/AIDS are urgently needed. Whereas transgender populations experience some of the highest rates of HIV infection in the United States with estimates of HIV infection prevalence ranging from 14 to 69%; Whereas transgender individuals who are also members of other disadvantaged populations, such as transgender people of color and transgender women, bear an extremely heavy burden of HIV infection; Whereas discrimination against transgender people in areas of everyday life such as education, housing, and employment contributes to elevated rates of homelessness, poverty, recourse to underground economies such as sex work, and incarceration, all of which are known drivers of HIV risk; Whereas transgender populations experience significant health disparities, including elevated rates of substance use, mental health concerns such as depression, encounters with violence, and sexually transmitted infections, that contribute to higher risk of HIV infection; Whereas transgender people frequently encounter barriers to health care, including a lack of insurance, fear of discrimination, provider insensitivity or hostility, and lack of knowledge about transgender health; Whereas these barriers prevent many transgender people from accessing effective HIV prevention services, learning their HIV status, taking steps to connect with care when they are HIV-positive, or staying in care to help manage their HIV status; People are also finding other ways to identify their gender. As Washington Post columnist Steven Petrow points out, after he went to a presentation at Duke University’s Center for Sexual and Gender Diversity, he found some trans people used the pronouns "ze" and "hir." Other non-gender pronouns with which people identify can also include "ve/ver," "xe" and "ni/nem.“ Handy dandy list of pronouns! The list of pronouns being used in the English language is ever growing, so here is a list of the ones we know. This is not meant to be an exhaustive list, and we plan to keep it updated as much as we can. If you know of a set of pronouns that should be on this list, let us know! We should also point out that some people don’t want you to use pronouns at all; they would simply prefer that you just use their name. Additionally, more and more people are using “they”, “them”, and “their(s)” as singular, gender inclusive pronouns, even though they have been traditionally used as plural pronouns. SUBJECT PRONOUN OBJECT PRONOUN POSSESSIVE PRONOUN REFLEXIVE PRONOUN ____ is an activist. I am proud of _____. That is _____ book. -or- That book is _____. That person likes _____. She her her/hers herself He him his himself Ze* hir hir/hirs hirself Ze* zir zir/zirs zirself E or Ey em eir/eirs eirself or emself Per per per/pers Perself Hu hum hus/hus Humself They (are)** them their/theirs Themselves Name Name Name’s/Name’s Name *Additional alternate spellings for “ze” are “zie”, “sie”, “xie”, and “xe.” **When using “they” as a singular gender inclusive pronoun, you would still conjugate associated verbs as you would for the plural version, as in “they are an activist” or “they like to go shopping”, not “they is an activist” or “they likes to go shopping.”
- #13 Substance use, abuse, and dependence been closely associated with HIV infection since the beginning of the epidemic. Although injection drug use (IDU) is a direct route of transmission, drinking, smoking, ingesting, or inhaling drugs such as alcohol, crack cocaine, methamphetamine (“meth”), and amyl nitrite (“poppers”) are also associated with increased risk for HIV infection. These substances may increase HIV risk by reducing users’ inhibitions to engage in risky sexual behavior. Substance use and addiction are public health concerns for many reasons. In addition to increasing the risk of HIV transmission, substance use can affect people’s overall health and make them more susceptible to HIV infection and, in those already infected with HIV, substance use can hasten disease progression and negatively affect adherence to treatment. Vulnerable Populations •People who live in poverty. People who live in disadvantaged neighborhoods are more likely to have high rates of alcohol and illicit drug use. •Gay and bisexual men. Alcohol and drug use among gay and bisexual men can be a reaction to homophobia, discrimination, or violence they experienced because of their sexual orientation and can contribute to other mental health problems. Compared with the general population, gay and bisexual men ◦Are more likely to use alcohol and drugs. ◦Are more likely to continue heavy drinking later in life. ◦Have higher rates of substance abuse. •People with a mental illness. The coexistence of substance use and mental health disorders is common and is linked to poor impulse control and greater risk-taking and sensation-seeking behaviors. •People with a history of abuse. People who have experienced sexual, physical, or emotional abuse are more likely to overuse drugs and alcohol and practice risky sexual behaviors. What Steps CDC are Taking: CDC and its partners are pursuing a high-impact prevention approach to advance the goals of the National HIV/AIDS Strategy for the United States and maximize the effectiveness of current HIV prevention methods. This approach centers on using combinations of scientifically proven, cost-effective, and scalable interventions targeted to populations at greatest risk for HIV infection, including substance abusers; this approach promises to increase the impact of HIV prevention efforts. Behavior risk reductions and other public health strategies (syringe services programs, community outreach, and substance abuse treatment programs) anchor evidence-based prevention strategies for reducing HIV transmission between substance users and their sex partners. In 2006, CDC released Revised Recommendations of HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. These revised recommendations advise routine HIV screening of adults, adolescents, and pregnant women in health care settings in the United States and repeat testing for people with risk behaviors since their last test, including exchange of sex for drugs. CDC supports the national dissemination of effective HIV behavioral interventions for substance abusers that are delivered by health departments and community-based organizations around the country. These interventions include: •Community PROMISE (for any drug users). •Modelo de Intervención Psicomédica (MIP, for Latino injection drug users). •Safety Counts (for crack cocaine smokers and injection drug users). •SHIELD (for any drug user social networks).
- #14 Brian Gazzard, MD, of Chelsea and Westminster Hospital in London, United Kingdom, reported on emerging areas of interest concerning a diverse range of issues related to basic scientific research, clinical care, and prevention, with snippets of data for each. Dr. Gazzard briefly touched on a few areas that are under investigation as biomedical strategies to reduce HIV transmission/acquisition. Circumcision. This surgical procedure can be done in developing countries for the approximate equivalent of $US10, and short-term studies show that efficacy in preventing female-to-male transmission is 60% to 80%. Furthermore, it is highly cost-effective. Microbicides. Advantages of this intervention are the low cost of the intervention and that it is a female-controlled prevention technology. Concerns are that large trials are necessary for approval (sample size of 10,000 was noted) for each agent, and that there is also a potential for cervical damage. Vaccine. Dr. Gazzard made his case for immune activation as a critical issue in vaccine development. This is supported by studies in the sooty mangabey, which has a high simian immunodeficiency virus (SIV) viral load (106-107 copies/mL), yet there is no activation of CD4+ cells and no disease progression. Dr. Gazzard offered apologies to Dr. Anthony Fauci before he strongly expressed his belief that cytotoxic T-lymphocyte (CTL) response is not important in controlling HIV replication. While viral eradication remains the "Holy Grail" of AIDS research, it is believed that any cure will require stimulation of CD4+ memory cells and macrophages/monocytes. Studies with valproic acid are prototypic. Fortunately, we clinicians now have many therapeutic options in our arsenal. With the advent of highly effective antiretroviral drug regimens that have been fine-tuned over time, antiretroviral potency is no longer the most critical issue in HIV management. The main challenges now are toxicity and adherence. Adherence.The relationship between adherence and resistance is quite different for the antiretroviral drug classes, as shown by Bangsberg and colleagues.[1,2] For instance, for unboosted protease inhibitors (PIs), higher rates of drug resistance are associated with higher rates of adherence; but for nonnucleoside reverse transcriptase inhibitors (NNRTIs), higher rates of drug resistance correlate with lower rates of adherence. Another key difference should be noted that pertains to barriers to adherence among patient populations in resource-rich vs resource-limited settings. Meta-analysis of trials in developing countries show that adherence rates average 77% of prescribed dose, which is far better than the 54.7% achieved in North America. The main reason for drug failure in Europe and the United States is lifestyle choices; in developing countries, it is the often challenging logistics surrounding drug availability/access. Toxicity/Adverse Effects.The preferred regimen for initial treatment of HIV infection in 2006 is NNRTI-based highly active antiretroviral therapy (HAART), as established in ACTG 5142. With regard to cardiovascular toxicity, the concern for this complication is inappropriate. The D:A:D study shows that the odds ratio for PI-based HAART is only 1.16 (P < .05) and for NNRTI-based HAART it is 1.05, which is not statistically significant compared with untreated controls.[3] NNRTI-based HAART is also more cost-effective compared with PI-based HAART (£12,199 vs £14,049). Thus, NNRTI-based HAART is more potent, less demanding for adherence, less likely to cause cardiovascular complications, and less expensive. HIV Prevention HIV Management: Current Issues and Challenges Table 1. Testing HLA* B5701 to Detect Abacavir Hypersensitivity With regard to nucleoside reverse transcriptase inhibitor (NRTI) pairs, the major limitation is the hypersensitivity reaction associated with abacavir, but this can now be largely predicted by tests for genetic susceptibility by analysis for HLA* B5701, although these tests are expensive and not widely available in the United States. Malal 2002[4] Hetherington 2002[5] Pos Neg Pos Neg Sensitivity 14 4 36 29 Specificity 5 177 8 649 Sensitivity 78% 55% Specificity 97% 99% Pos predictive value 74% 82% Neg predictive value 98% 96% This test is now standard in the United Kingdom, and Dr. Gazzard stated that he knows of only 1 abacavir hypersensitivity reaction in a patient with a negative test. Studies show a sensitivity of 78% and a specificity of 97%.[4,5] Dr. Gazzard also predicted that zidovudine will cease to be used as a first-line agent due to toxicity including lipoatrophy.[6] He suggested that the emerging paradigm will be: (tenofovir + emtricitabine or abacavir + lamivudine) + NNRTI, 2 new drugs (eg, darunavir + integrase inhibitor): 2 more new drugs Most promising are integrase inhibitors such as MK-0518. In triple-class-experienced patients with virologic failure, the initial report showed that 63% to 67% of patients given MK-0518 achieved a viral load < 400 copies/mL, compared with 8% in controls.[7] There were no discontinuations due to adverse reactions. In protocol 004 in treatment-naive patients, the results with 4 dosing regimens vs efavirenz showed no dose-related toxicity; there was comparable antiviral activity at 24 weeks, but all MK-0518 patients achieved undetectable viral load much faster (P < .001 for each dose) vs efavirenz. Studies of salvage therapy have shown the following: Study Approximate Percentage of Patients With HIV RNA < 50 Copies/mL TORO 1 & 2 (enfuvirtide) 20 RESIST 1 & 2 (tipranavir) 20 POWER (darunavir) 50 Entry inhibitor (vicriviroc) 40 Integrase inhibitor (MK-0156) 70 NNRTI (TMC 125) 20 Bangsberg DR, Acosta EP, Gupta R, et al. Adherence-resistance relationships for protease and nonnucleoside reverse transcriptase inhibitors explained by virological fitness. AIDS. 2006;20:223-231. Bangsberg DR. Less than 95% adherence to nonnucleoside reverse transcriptase inhibitor therapy can lead to viral suppression. Clin Infect Dis. 2006;43:939-941. Epub 2006 Aug 23.c, Friis-Moller N, Reiss P, El-Sadr W, et al. Exposure to PI and NNRTI and risk of myocardial infraction: results from the D:A:D study. Program and abstracts of the 13th conference on Retroviruses and Opportunistic Infections; February 5-8, 2006; Denver, Colorado. Abstract 144. Mallal S, Nolan D, Witt C, Masel G, et al. association between presence of HLA-B*5701, HLA-DR7, and HLA-DQ3 and hypersensitivity to HIV-1 reverse-transcriptase inhibitor abacavir. Lancet. 2002;359:727-732. Hetherington S, Hughes AR, Mosteller M, et al. Genetic variations in HLA-B region and hypersensitivity reactions to abacavir. Lancet. 2002;359:1121-1122. Mallal SA, John M, Moore CB, James IR, McKinnon EJ. Contributions of nucleoside analogue reverse transcriptase inhibitors to subcutaneous fat wasting in patients with HIV infection. AIDS. 2000;14:1309-1316. Grinstein B, Nguyen B, Katlama C. Potent efficacy of Mk-0518, a novel HIV-1 integrase inhibitor, in patients with triple-class resistant virus: 24-week data. Program and abstracts of the 46th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy; September 27-30, 2006; San Francisco, California. Abstract H-1670b. New Antiretroviral Drugs Table 2. Synopsis of Results Observed in Salvage Studies of Antiretroviral Therapy for HIV Infection References