lunes, 21 de marzo de 2011

Human Papillomavirus Infections in Men: Incidence and Clearance

Among HIV-negative men in three countries, the incidence of new genital HPV infection was 38.4 cases per 1000 person-months.
Human papillomavirus (HPV)-related cancers occur in men and women, yet little is known about the natural history of HPV infections in men. Now, investigators have conducted a prospective study to assess the incidence and clearance of HPV among HIV-negative men aged 18 to 70. (One of the investigators receives support from Merck, which produces an HPV vaccine.)
Participants were recruited from the general population, universities, and organized healthcare systems in the U.S., Brazil, and Mexico. Before enrollment and every 6 months thereafter, they underwent swabbing of the penis and scrotum for HPV testing (detection of DNA by polymerase chain reaction; genotyping) and completed a computer-based questionnaire.
Although the full cohort involved 4074 men, most analyses were conducted among the first 1159 who enrolled and completed ≥2 weeks of follow-up (mean age, 32.1; median follow-up, 27.5 months). The incidence of new genital HPV infection was 38.4/1000 person-months and did not vary with age. Median time to clearance was 7.2 months for oncogenic HPV types and 7.6 months for nononcogenic types. This interval was significantly longer in 18- to 30-year-olds than in older men. In multivariate analysis, oncogenic HPV infection was significantly associated with having a high number of lifetime female sexual partners or recent male anal-sex partners.
Comment: This study shows that HPV infection is common among men. An editorialist notes different natural histories in men and women: The rate of penile intraepithelial neoplasia is 10 to 20 times lower than the rate of cervical intraepithelial neoplasia, even though HPV infection rates are higher in men than in women. Because condoms provide only limited protection against HPV acquisition, the role of vaccination merits study. The present findings provide useful information about HPV acquisition and clearance in men. However, as the authors caution, the study cohort is a select population, so incidence estimates may not be generalizable to men in the three countries evaluated.
Published in Journal Watch Infectious Diseases March 9, 2011

Opt-Out HIV Testing: What Are We Waiting For?

Although the CDC recommends that HIV testing be performed in all clinical settings unless the patient refuses, several states still require written consent. This study shows why it's time for those laws to change.
An estimated 232,700 people in the U.S. are infected with HIV but do not know it. Many of them will engage with the healthcare system for reasons unrelated to their HIV status, and those visits represent opportunities for testing and awareness. To that end, the CDC has recommended since 2006 that HIV testing be performed in all healthcare settings on every patient aged 13 to 64, unless the patient explicitly declines (i.e., "opt-out" testing). However, for at least several years after that recommendation was issued, the laws in nine states (Alabama, Hawaii, Massachusetts, Michigan, Nebraska, New York, Pennsylvania, Rhode Island, and Wisconsin) continued to require written informed consent. In this modeling analysis, investigators estimated the survival gains that could occur with a change in those laws.
Based on published data from San Francisco (JW AIDS Clin Care Mar 26 2007), the researchers assumed that removing the requirement for written consent would increase the rate of HIV diagnosis by 48.5%. Under that assumption, having the nine states change their laws would result in a higher average CD4-cell count at diagnosis and a mean survival gain of 1.5 years per HIV-infected individual. This in turn would translate into a total of 537,399 life-years gained. (Even with only a 24.8% increase in the rate of diagnosis, 304,765 life-years would be gained.) These survival gains would vanish if the proportion of HIV-infected people who avoided testing exceeded 18.2%.
Comment: The results of this paper are based on modeling, and the estimates may be overly optimistic. Nonetheless, the states that have not yet changed their laws (4 at the time of this writing: Massachusetts, Michigan, Nebraska, and Pennsylvania) should pass legislation immediately to remove the requirement for written consent. Doing so would lead to earlier detection of HIV infection, longer survival times, and fewer new infections, all of which would advance the goals of the recently released National HIV/AIDS Strategy. Given the unacceptably high rate of HIV incidence in this country, we simply cannot wait any longer.
The Editor-in-Chief of Journal Watch AIDS Clinical Care was involved in the research described here. Consequently, he was not involved in the selection of this article for coverage, nor was he involved in the writing or review of this summary.
Published in Journal Watch HIV/AIDS Clinical Care March 14, 2011

CITATION(S):

April MD et al. Projected survival gains from revising state laws requiring written opt-in consent for HIV testing. J Gen Intern Med2011 Feb 1; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s11606-011-1637-5)

Putting PrEP into Practice — The Experts Respond

Two experts describe how they would manage our latest Antiretroviral Rounds case.
Last week, we described a high-risk young man seeking intermittent pre-exposure prophylaxis (PrEP) for HIV infection and asked whether you would be likely to prescribe PrEP for him. Of the nearly 400 people who responded to our poll, 45% said they would not prescribe PrEP, 35% said they would prescribe intermittent PrEP, and 20% said they would prescribe continuous PrEP. Now, two experts describe what they would do.

THE CASE

A 29-year-old man goes to the emergency department (ED) to request post-exposure prophylaxis (PEP) to prevent HIV infection. He has just returned from a week-long vacation, during which he had unprotected oral and receptive anal intercourse with several men whose HIV status he does not know. His last HIV test was 6 months prior to this ED visit, and the result was negative. He reports no medical problems and is not taking any medications. He receives a 28-day course of tenofovir/FTC + lopinavir/ritonavir PEP.
Four days later, the patient has a follow-up visit with his primary care provider (PCP), who is aware that he has received at least three similar courses of PEP during the previous 4 years. His HIV antibody test has again returned negative. He says he is aware of when he is going to put himself at high risk for HIV infection (usually during vacations and particular weekends) and would like a supply of tenofovir/FTC to take during these periods; however, he does not want to take the drugs continuously.
If you were the PCP, what additional history would you obtain? Would you try to change the patient's high-risk behavior? If so, what specifically would you say to him? Would you recommend tenofovir/FTC pre-exposure prophylaxis (PrEP) for him? If so, would it be continuous or intermittent? How frequently would you monitor for HIV, other sexually transmitted infections (STIs), and tenofovir/FTC toxicity? If you would not prescribe PrEP, what is your reasoning?

RESPONSE 1

— Anthony Mills, MD
I would begin with a frank, nonjudgmental discussion with this patient about his exposure history, including use of recreational drugs and alcohol, possible sources of infection, and the likelihood that any of his partners could be contacted for further inquiry. I would certainly have a heart-to-heart conversation with him about the risks that he is taking and would work with him to put together a risk-reduction plan, which may include referral to a case manager or psychotherapist to focus attention on why he takes these risks. I would also determine his hepatitis serology status and screen him for various STIs, including syphilis and hepatitis B and C.
Although the iPrEx study supports the use of PrEP in high-risk men who have sex with men (MSM; N Engl J Med 2010; 363:2587), I would only consider prescribing it to this particular patient after extensive testing and discussion. Establishing his HIV status for certain, although difficult, is a key priority. Men in iPrEx who were antibody-negative but HIV-infected at study entry were at risk for developing drug resistance. To ensure that this patient is truly HIV-negative, I would recommend that he undergo both HIV antibody testing and HIV viral-load testing 4 to 6 weeks after he has completed his course of PEP.
In discussing PrEP with this patient, I would emphasize that it should never be the first line of defense against HIV infection. PrEP has been shown to be beneficial only in the context of condom usage and regular testing for HIV and other STIs. Furthermore, oral PrEP must be taken every day. Although the use of tenofovir gel before and after sex reduced the risk for HIV infection among women in CAPRISA 004 (Science 2010; 329:5996), intermittent use of oral tenofovir/FTC was not effective among men in iPrEx and cannot be recommended without further study.
If this patient proves to be HIV-negative, is willing to work together to reduce his HIV risk, is willing to take PrEP every day, and is committed to close regular follow-up, then and only then would I consider PrEP for him. I would prescribe no more than a 90-day supply of tenofovir/FTC, and I would recommend follow-up visits at least every 3 months. At these visits, I would check his HIV antibody status (and other safety labs as needed), evaluate his adherence, assess his risk behaviors, test and treat for other STIs, and provide risk-reduction counseling, condoms, and his next 90-day PrEP prescription.

RESPONSE 2

— Demetre C. Daskalakis, MD
I would obtain a social and mental health history to better understand what might be influencing this patient's sexual risk-taking. I would explore his use of alcohol and recreational drugs, such as methamphetamine, and assess the need for a referral to mental health care. I would also ask him why he engages in unprotected sex and confirm that he understands the medical implications of HIV infection. Finally, I would also search for symptoms of acute HIV infection and other STIs.
Changing his sexual behavior would be difficult. Although PCPs have a role in risk reduction, this patient requires more-intensive prevention counseling than is offered in a standard medical practice.
I would not prescribe PrEP to this patient at this time. He has expressed a clear desire for intermittent antiretroviral use, but no data are available on the safety and efficacy of this intervention. The iPrEx study only supports daily PrEP with a high level of adherence (N Engl J Med 2010; 363:2587), and I am concerned that we do not know enough about the correct timing of intermittent PrEP to ensure preventive efficacy. A broader issue is that the healthcare system currently lacks the infrastructure to support PrEP care in the manner recommended by the CDC (MMWR Morb Mortal Wkly Rep 2011; 60:65). For example, although the CDC recommends PrEP use in high-risk MSM, there is little if any third-party payer coverage of antiretrovirals for preventive indications.
For MSM who are willing to take continuous PrEP and are able to pay for their own drugs (and, potentially, for HIV and STI testing as well, if the frequency required is not covered), I would consider prescribing daily tenofovir/FTC. I would follow the CDC PrEP guidance, with some variation based on my HIV primary care experience. For example, the CDC recommends testing for HIV every 2 to 3 months and for other STIs every 6 months; however, I would test for both every 2 to 3 months, regardless of symptoms. Similarly, the CDC recommends evaluating renal function at baseline, at 3 months, and then annually. However, I would check renal function more frequently and also assess baseline liver function, evaluate blood counts, and perform a urinalysis to monitor drug toxicity.

FOLLOW-UP

As anyone practicing HIV medicine or engaged in HIV research can tell you, the publication of the iPrEx study raised as many questions as it answered. Nonetheless, the application of the study results to clinical practice has already become a reality.
The case presented here — adapted from one seen in our clinic only a month after the iPrEx results were released — raised considerable controversy among our providers, most of whom thought the patient should not be prescribed PrEP because he was not committed to continuous therapy. This view was shared by our two expert respondents and by most of the readers who weighed in with comments or votes online. Of considerable interest is that the second most common response was to prescribe intermittent PrEP, even though this strategy has not yet been shown in clinical studies to be effective.
Despite this majority view not to prescribe PrEP, one respondent raised an interesting point under the title "Double Standard?" She writes:
"How is this different than prescribing a PPI for heartburn when a patient refuses to give up coffee or a statin for hypercholesterolemia when a patient will not make dietary modifications? Our business is to prescribe medicines to mitigate risk when people do not (for whatever reason) make healthy lifestyle choices."
Indeed, this legitimate perspective in favor of PrEP highlights just how challenging the issue of PrEP will be in clinical practice.
Dr. Mills is in private practice in Beverly Hills and is an Assistant Professor of Clinical Medicine at the University of California, Los Angeles. He reports no conflicts of interest.
Dr. Daskalakis is an Assistant Professor of Medicine and Director of the Men's Sexual Health Project at New York University Medical Center. He reports no conflicts of interest.
Published in Journal Watch HIV/AIDS Clinical Care March 14, 2011

La tuberculosis multirresistente aumenta en Europa

JANO.es y agencias · 21 Marzo 2011 09:15
Vota 
Resultado 
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La OMS y el ECDC alertan de que el número de casos está incrementándose en Europa del Este, Asia y África Subsahariana, y amenaza con minar los avances logrados por los programas de control a escala mundial.

Mycobacterium tuberculosis.
La Organización Mundial de la Salud (OMS) y el Centro Europeo para la Prevención y el Control de Enfermedades (ECDC) manifestaron el pasado viernes su preocupación por el aumento en Europa de la tuberculosis multirresistente, que está burlando todos los programas mundiales dirigidos a reducir los casos y aumentando entre los niños.
 
Un artículo firmado por los investigadores Alimuddin Zumla, del University College London Medical School, y Stephen Lawn, la Universidad de Cape Town, publicado en The Lancet, indica que África Subsahariana está viéndose afectada de forma desproporcionada por esta enfermedad, que supone ya 4 de cada 5 casos de tuberculosis asociada al VIH.
 
Según los investigadores, “las tasas de tuberculosis multirresistente van en aumento en Europa del Este, Asia, África Subsahariana y ahora amenazan con minar los avances logrados en este campo por los programas para el control de la tuberculosis a escala mundial”.
 
Señalan que las crecientes tasas globales de diabetes y las altas tasas de tabaquismo entre los habitantes de los países de ingresos medios y bajos estaban conduciendo hacia una epidemia de tuberculosis. La diabetes multiplica por tres el riesgo de desarrollar tuberculosis y el tabaquismo lo duplica.
 
Estos expertos aseguran que los avances hacia el control de la tuberculosis en todo el mundo han sido obstaculizados por la ausencia de un test diagnóstico rápido y barato, la larga duración de los tratamientos, la falta de una vacuna efectiva, las crecientes tasas de tuberculosis resistentes a fármacos y el débil sistema de salud que presentan los países pobres.
 
La tuberculosis mata a cerca de 1,7 millones de personas cada año y el número de casos a nivel mundial -más de 9 millones- es mayor ahora que en ningún otro momento de la historia, han destacado estos investigadores.
 
Según los datos de la Oficina Europea de la OMS, las tasas de tuberculosis han estado bajando en Europa desde el año 2005, con una media regional situada en las 36,8 notificaciones por cada 100.000 habitantes, en 2009. Sin embargo, las tasas de notificación de nuevos casos y las recaídas en 18 países de alta prioridad siguen siendo al menos ocho veces mayor que en el resto de la región.
 
“Las poblaciones vulnerables, incluidos los niños, aún no tienen acceso a un diagnóstico y a un tratamiento oportuno y de calidad”, apunta el informe de la OMS y el ECDC, donde se apunta también que “este asunto sigue siendo una urgencia, dada la alta prevalencia de la tuberculosis resistente y multirresistente en la región”.
 
Más de una tercera parte de la población mundial está infectada con la bacteria que causa la tuberculosis, pero sólo un pequeño porcentaje desarrolla alguna vez la enfermedad. Diversos estudios han demostrado que las personas con problemas de abuso de sustancias, que son pobres y aquellos que viven en comunidades de difícil acceso son más propensas a la tuberculosis.




The Lancet 2011;doi:10.1016/S0140-6736(10)62173-3

Once-Daily Darunavir in Treatment-Experienced Patients: ODIN Results Published

In HIV-infected patients with no darunavir resistance–associated mutations, once-daily darunavir is as effective as twice-daily darunavir, with fewer adverse events.
Darunavir was initially approved for treatment-experienced patients at a dose of 600 mg, with 100 mg of ritonavir, twice daily. However, data from the POWER 1 and 2 trials suggested that the once-daily dose approved for use in treatment-naive patients — 800 mg, with 100 mg of ritonavir — might also be effective in treatment-experienced patients with no baseline darunavir resistance. The ODIN trial, a phase III, open-label, manufacturer-funded study, was designed to evaluate this possibility.
A total of 590 patients who were on a failing regimen and had no darunavir resistance–associated mutations were randomized to receive ritonavir-boosted darunavir either once daily (800 mg, with 100 mg of ritonavir) or twice daily (600 mg, with 100 mg of ritonavir). Both groups received optimized background regimens consisting of ≥2 nucleoside reverse transcriptase inhibitors. Forty-six percent of the patients had never received a protease inhibitor (PI) before, and 84% of the patients had no major PI mutations.
At week 48, 72% of the once-daily group and 71% of the twice-daily group achieved viral loads <50 copies/mL, establishing noninferiority of the once-daily dose. Only one patient with virologic failure (in the once-daily group) developed major PI mutations. The once-daily group had fewer triglyceride elevations and lower cholesterol levels (total and LDL) than the twice-daily group.
Comment: Based on the results of this trial, on December 13, 2010, the FDA approved once-daily dosing of ritonavir-boosted darunavir for treatment-experienced patients with no darunavir resistance–associated mutations. As the authors point out, most treatment-experienced patients do not have such mutations. For the subset of patients who do, twice-daily dosing should continue to be used.
Published in Journal Watch HIV/AIDS Clinical Care March 21, 2011

viernes, 18 de marzo de 2011

CONFERENCIA SOBRE LA CO-INFECCION HIV-TB ON LINE

TB & HIV: A Deadly Duo

Thursday, March 24, 2011
11 a.m. – 12 p.m., E.D.T.
Watch the live broadcast at:
http://cdc.wl.miisolutions.net/live/cdc/6
For slower or dial-up connections:
http://cdc.wl.miisolutions.net/live/cdc/7
NOTE: presention will be archived 48 hours following the live event
As we commemorate Dr. Robert Koch’s 1882 discovery of Mycobacterium tuberculosis, the bacteria that causes TB, we are reminded of the many advances over the past 129 years in TB control. Through the intervention efforts of CDC, USAID, WHO’s Stop TB Partnership, and many others, TB death rates have fallen by 35% since 1990, and as many as 6 million lives have been saved since 1995.
In spite of these successes, TB still remains a serious threat, especially for those infected with HIV. HIV is the single most powerful risk factor for TB disease and one of the leading causes of death among people infected with HIV. Among the 1.7 million lives that TB claimed in 2009, 380,000 were among people with HIV infection. While people with HIV who have TB can be effectively diagnosed and treated, more effort is needed to diagnose and treat TB promptly and effectively, and to scale-up preventive treatment for TB.
World TB Day presents CDC and its partners with a prime opportunity to discuss TB/HIV-related problems and solutions while renewing our support for worldwide TB control efforts. This special session of Public Health Grand Rounds seeks to dispel myths and misconceptions about TB and HIV, discuss actions needed to reduce the spread and burden of TB, and advance our efforts in preventing deaths from TB/HIV.

Presented By:

Jay Varma, MD
Chief, International Emerging Infections Program - China
Division of Global Disease Detection and Response, Center for Global Health, CDC
Presentation: TB and HIV: Friends With(out) Benefits
Kevin Cain, MD
Chief, TB/HIV Team, International Research and Programs Branch,
Division of TB Elimination, National Center for HIV/AIDS, Viral Hepatitis,
STD, and TB Prevention, CDC
Presentation: You Have to Find TB to Treat TB
Taraz Samandari, MD, PhD
Chief, Epidemiology Branch,
Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis,
STD, and TB Elimination, CDC
Presentation: If Finding TB is so Difficult, Why Not Just Prevent It?
Mario Raviglione, MD
Director, STOP TB Department, World Health Organization (WHO)
Presentation: From Science to Policy to Impact
Thomas R. Frieden, MD, MPH
Director, CDC
Presentation: Fundamentals are Fundamental

Facilitated By:

Tanja Popovic, M.D., Ph.D., Scientific Director, Public Health Grand Rounds
Shane Joiner, Communication Manager, Public Health Grand Rounds

Additional Resources:

TB & HIV Fact Sheets: TB and HIV Coinfection

jueves, 10 de marzo de 2011

Situación del SIDA en la provincia de PICHINCHA


https://sites.google.com/site/svemsidapns2011/documentos-relacionados-con-el-estado-de-la-epidemia-vih-sida-e-its-en-el-ecuador

INFORME DEL INSTITUTO NACIONAL DE HIGIENE Y MEDICINA TROPICAL "lEOPOLDO IZQUIETA PEREZ" del mes de Enero 2011 sobre confirmados de VIH en Ecuador

Estimados colegas, según el reporte del INH, enviado el 21-02-2011, se han recibido 2637 pruebas , de las cuales 380 pruebas fueron confirmadas con WB, en el mes de Enero del 2011.

Este año comenzamos con 380 casos confirmados de ser portadores del VIH a nível del país.


Saludos

Dr. Carlos Erazo

Premastication of Food by Caregivers of HIV-Exposed Children --- Nine U.S. Sites, 2009--2010

Estimados colegas, les dejo otra noticia sobre VIH.
Saludos
Dr. Carlos Erazo

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6009a2.htm?s_cid=mm6009a2_e&source=govdelivery

Weekly

March 11, 2011 / 60(09);273-275


Premastication (i.e., chewing foods or medicines before feeding to a child) was reported recently as a route of human immunodeficiency (HIV) transmission through blood in saliva (1) and has been associated with transmission of other pathogens (2--7). Approximately 14% of caregivers in the United States report premastication (8); however, the frequency of this behavior among HIV-infected caregivers is unknown. To assess the prevalence of premastication among caregivers of children being treated in pediatric HIV clinics, which include perinatally HIV-exposed children (i.e., HIV-uninfected and HIV-infected children born to an HIV-infected mother), CDC conducted a cross-sectional survey at nine such clinics in the United States during December 2009--February 2010. This report describes the results of that survey, which indicated that among primary caregivers of children aged ≥6 months, 48 (31%) of 154 reported the children received premasticated food from themselves or someone else. Approximately 37% of black caregivers reported premastication, compared with 20% of non-black caregivers (prevalence ratio [PR] = 1.8). Premastication decreased with caregiver age and was used to feed children aged 1--36 months. Public health officials and health-care providers should educate the public about the risk for disease transmission via premastication and advise HIV-infected caregivers against the practice.
Pediatric HIV clinics with which the CDC had collaborated previously in premastication-related or longitudinal, HIV-related epidemiologic studies participated in this investigation. These clinics were located in Atlanta, Georgia; Dallas, Texas; Houston, Texas; Memphis, Tennessee; Miami, Florida; New Orleans, Louisiana; Newark, New Jersey; San Juan, Puerto Rico; and the District of Columbia. A 10-minute, self-administered paper questionnaire was distributed to primary caregivers during their child's clinic visit. A primary caregiver was defined as the person responsible for feeding, clothing, and housing the child. One survey per child with an appointment was allowed; therefore, multiple interviews were possible if a caregiver had multiple children with appointments. After completion of the survey, caregivers were provided written information and counseled about the risk for disease transmission through premastication. Of 203 primary caregivers approached, 192 (95%) were surveyed (11 declined participation).
Of the 192 primary caregivers surveyed, the majority were biologic mothers of the children (81%) and U.S.-born (86%). Approximately 66% of caregivers were non-Hispanic black, 24% were Hispanic, and 7% were non-Hispanic white. The median age was 31 years for primary caregivers (range: 15--77 years) and 2 years for children (range: <1--18 years). Approximately 30% of caregivers had less than a high school education, and 49% had an annual household income of less than $12,000.
Given the decreased likelihood that children are fed solid foods during the first months of life, CDC limited its analysis to caregivers of children who were aged ≥6 months at the time of investigation (155 [81%] of 192). Among primary caregivers of these children, 44 (29%) of 153 reported ever premasticating food for the child. Fourteen (10%) of 140 primary caregivers reported that someone else had given premasticated food to the child. Overall, 48 (31%) of 154 primary caregivers stated that they or someone else had premasticated food for the child, with biologic mothers representing 79% of premasticators. Black caregivers more frequently reported ever premasticating food, compared with non-blacks (37% versus 20%, respectively; PR = 1.8) (Table 1). Premastication decreased with increasing caregiver age at interview. Caregivers aged ≤19 years were significantly more likely to premasticate than those aged ≥40 years (44% versus 13%, respectively; PR = 3.5), as were those aged 20--29 years (38% versus 13%, respectively; PR = 2.9) and those aged 30--39 years (36% versus 13%, respectively; PR = 2.8). Similar prevalences of premastication were found regardless of the sex of the child and the primary caregiver's country of origin, education level, and income (Table 1).
Primary caregivers started premastication of food for children as young as age 1 month (median age: 7 months) and stopped premastication as late as age 36 months (median age: 13 months). Among 38 premasticating primary caregivers who described frequency of the behavior, 15 (39%) reported premasticating 1--3 days in a typical week, 14 (36%) reported 4 or more days, and nine (24%) reported less than once a week. The most commonly reported reasons for premastication, reported from a predetermined list, were "child wanting some of the caregiver's food" (64%), "caregiver not wanting the child to choke" (62%), and "prechewing is done in my family" (31%) (Table 2). Meat and fish (80%) and fruit (39%) were the most commonly reported food types premasticated by caregivers.

Reported by

N Rakhmanina, MD, Children's National Medical Center; S Hader, MD, A Denson, Dept of Health, Washington, DC. A Gaur, MD, St. Jude Children's Research Hospital, Memphis, Tennessee. C Mitchell, MD, Miller School of Medicine, Univ of Miami. S Henderson, MD, Emory Univ, Atlanta, Georgia. M Paul, MD, Baylor College of Medicine, Texas Children's Hospital, Houston; T Barton, MD, Southwestern Medical Center, Dallas, Texas. M Herbert-Grant, MD, University Hospital, New Jersey Medical School. E Perez, Univ of Puerto Rico. J Malachowski, Tulane Univ School of Public Health, New Orleans, Louisiana. K Dominguez, MD, S Danner, S Nesheim, MD, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; W Ivy, PhD, D Iuliano, PhD, EIS officers, CDC.

Editorial Note

In 2007, an estimated 13% of 159 diagnoses of HIV and acquired immunodeficiency syndrome (AIDS) among children aged <13 years were attributed to modes other than perinatal transmission, including hemophilia, blood transfusion, and risk factors not reported or identified.* In 2008, a case series of three pediatric HIV cases concluded that premastication was the likely mode of transmission for these children, a route not reported previously (1). Bleeding gums at the time of premastication were reported in caregivers of two of the three children in the case series. The third caregiver could not recall her dental condition at the time of premastication. One of these transmissions was to a child whose mother was not HIV-infected. HIV transmission via premastication is presumed to require blood in the mouth of the caregiver. No evidence suggests that saliva alone can transmit HIV.
In addition to HIV, transmission of hepatitis B virus (3) and group A streptococcus (6) by premastication has been documented. Furthermore, premastication has been found to be associated with increased risk for infection with Helicobacter pylori (7), Streptococcus mutans (2), human herpesvirus 8 (4), and Epstein Barr virus (5). Only one study has indicated that premastication can be associated with decreased risk for infection; that study involved respiratory syncytial virus in Alaska Native infants aged <6 months (9).
The prevalence of premastication observed in this investigation is particularly important because most of the caregivers and premasticators were biologic mothers; thus, most caregivers were HIV-infected, posing a potential risk for HIV transmission to children in their care who are uninfected. Furthermore, the higher prevalence of premastication among black and younger caregivers suggests the need for targeted prevention messages for these populations.
The reasons given by caregivers for premastication might suggest that the practice is mostly situational or in response to immediate circumstances, as opposed to reasons that reflect an inability to provide baby food or formula. Therefore, prevention messages might be effective among this population, particularly those with situational reasons for premastication. Qualitative research on premastication might be helpful to explore the reasons for premastication and to determine helpful, realistic alternatives for HIV-infected caregivers.
The findings in this report are subject to at least three limitations. First, gathering HIV status information on caregivers was not possible because surveys were completed in a setting where caregivers were accompanied by their children and other family members, some of whom might have been unaware of their caregiver's HIV status. However, given that all caregivers were surveyed in pediatric HIV clinics and 81% of primary caregivers were biologic mothers, the majority of the caregivers surveyed likely were HIV-infected. Second, the surveyed caregivers were asked to recall behaviors that might have taken place several years before survey administration; therefore, these data might be affected by recall bias. Finally, this cross-sectional investigation included a convenience sample of caregivers of children seen in HIV clinics and is not generalizable to all HIV-infected caregivers.
Although research on the risk for HIV transmission via premastication is limited, CDC recommends that HIV-infected caregivers not premasticate food for HIV-uninfected children because of the possibility of transmitting HIV to the child. Public health officials and health-care providers should continue to educate the public about the risk for disease transmission, including HIV, via premastication.

References

  1. Gaur AH, Dominguez KL, Kalish ML, et al. Practice of feeding premasticated food to infants: a potential risk factor for HIV transmission. Pediatrics 2009;124:658--66.
  2. Harrison R, Benton T, Everson-Stewart S, Weinstein P. Effect of motivational interviewing on rates of early childhood caries: a randomized trial. Pediatr Dent 2007;29:16--22.
  3. Huang MJ. An epidemiological study on prevalence and risk factors of hepatitis B virus (HBV) infection in preschool children [Chinese]. Zhonghua Liu Xing Bing Xue Za Zhi 1990;11:129--32.
  4. Mbulaiteye SM, Pfeiffer RM, Whitby D, Brubaker GR, Shao J, Biggar RJ. Human herpesvirus 8 infection within families in rural Tanzania. J Infect Dis 2003;187:1780--5.
  5. Mbulaiteye SM, Walters M, Engels EA, et al. High levels of Epstein-Barr virus DNA in saliva and peripheral blood from Ugandan mother-child pairs. J Infect Dis 2006;193:422--6.
  6. Steinkuller JS, Chan K, Rinehouse SE. Prechewing of food by adults and streptococcal pharyngitis in infants. J Pediatr 1992;120(4 Pt 1):563--4.
  7. Taylor DN, Blaser MJ. The epidemiology of Helicobacter pylori infection. Epidemiol Rev 1991;13:42--59.
  8. Fein SB, Labiner-Wolfe J, Scanlon KS, Grummer-Strawn LM. Selected complementary feeding practices and their association with maternal education. Pediatrics 2008;122(Suppl 2):S91--7.
  9. Bulkow LR, Singleton RJ, Karron RA, Harrison LH. Risk factors for severe respiratory syncytial virus infection among Alaska native children. Pediatrics 2002;109:210--6.

miércoles, 9 de marzo de 2011

Guia sobre indicadores para la vigilnacia y notificacion de la respuesta del sector salud VIH/SIDA Enero 2011

Añadir leyenda

New data from PrEP study shed light on adherence, bone mineral loss and resistance

Estimados colegas les dejo esta información que la pueden encontrar en el siguiente link:

http://www.aidsmap.com/page/1682919/
 
Saludos 
Dr. Carlos Erazo
 
Gus Cairns
Published: 02 March 2011
Bob Grant, lead investigator of iPrEx. Photo by Gus Cairns/aidsmap.com
Near-perfect adherence to oral pre-exposure prophylaxis – taking HIV drugs to prevent HIV – may be achievable in the right settings, the eighteenth Conference on Retroviruses and Opportunistic Infections heard yesterday.
Participants from the US sites of the international iPrEx study of tenofovir/FTC (Truvada) pre-exposure prophylaxis (PrEP) in men who have sex with men and transsexual women had near-perfect adherence, compared with 50% adherence from other sites, new data presented at the conference shows.
Analysis also found that adherence in men who had the highest risk of acquiring HIV, by having unprotected receptive anal sex, was, at 76%, far higher than those at lower risk, so participants were tempering their pill-taking to their perceived risk.
Another substudy has found that taking Truvada resulted in a small but significant loss in bone mineral density in participants. But it also found that participants’ bone mineral density at the start of the study was considerably lower than would have been expected in men their age.
Resistance tests uncovered no drug resistance in men who seroconverted (became infected with HIV) on the trial, but did find that one participant who took placebo had a small amount of virus with the K65R resistance mutation to tenofovir.
At a discussion forum on iPrEx and on the CAPRISA 004 microbicide trial, lead investigator Bob Grant announced that the US Food and Drug Administration had agreed that the iPrEx trial findings were sufficient for the FDA to move ahead and consider changing the indication for Truvada to include using it to prevent HIV.
PrEP, as a result, might be approved in the US by the end of this year.

Updated trial results

In the paper published on the trial findings in the New England Journal of Medicine last November, data were given up to May 2010. Bob Grant presented final figures for the trial, whose last participants left the trial in August 2010.
The final tally was that 130 HIV infections were seen in the 2499 men taking part in the trial, 48 of those taking Truvada and 82 on placebo, a rate of 2.6% a year. There were also 10 infections in men who had acute HIV symptoms at the time they enrolled, two of whom appear to have acquired resistance to FTC, and six infections in the three months immediately following the trial, four of them in men who had taken Truvada.
This means that the final efficacy figure in the ‘modified intent to treat’ (MITT) analysis, which excluded the men who had HIV at the start of the study and ignores factors like adherence and sexual risk, was 42%.
Efficacy was greater in men over 25 (56%), in men who reported greater than 90% adherence (68%), and, for reasons that are unclear, in the relatively small number of men who were circumcised (76%).

Adherence

One of the surprises of the original trial was that while mean reported adherence was 95%, a study of drug levels found that only 50% of a random sample of men who did not acquire HIV had detectable drug in their white blood cells. Only 9% of those who seroconverted had any drug in their cells either. Drug can be detected in cells for several weeks and this shows, in the words of Bob Grant, that “people were either taking it daily or not at all”.
A new analysis of drug levels in 179 participants by Peter Anderson of the University of Colorado confirmed that only 50% had detectable tenofovir in their cells and 62% detectable FTC. However 97% of the 227 participants from the two sites in the USA, in San Francisco and Boston, had detectable drug, showing that adherence was near-perfect in this more treatment-literate group. It also confirmed that adherence was better in men over 25 (73%) than men under 25 (44%).
Adherence analysis also showed that participants tempered their adherence according to their level of risk; 76% of those who had had unprotected receptive anal sex in the previous twelve weeks had significant drug levels versus 36% of those who had not and 25% of those who had had no sex at all.
Rivet Amico of the University of Connecticut presented an analysis of how self-reporting and pill counts correlated with actual adherence in the study. There were four measures of adherence taken during the study: self-reports by interview and by computer-assisted interview, pill count of the number of pills dispensed minus those returned, and the medication possession ratio (MPR), which was a measure, based on refill rates, of how many pills the participants had relative to the number that would last exactly till the next visit (thus an MPR of 1.25 meant they had 25% more pills than the minimum needed).
MPR was the most accurate guide to actual adherence. Only 68% of those claiming 100% adherence by self-report were actually adherent; only 62% of those claiming 100% adherence by computer-assisted interview; and only 59% of those assessed as having 100% adherence by pill count. But 75% of those assessed as having 100% adherence by MPR actually were so. The overall ‘positive predictive value’ of a claim of 100% adherence was 69%, meaning that 31% of those assessed as having 100% adherence did not. The ‘negative predictive value’ of a claim of less than 100% adherence was 95%, however, meaning that self-reports of poor adherence could be relied on.

Bone mineral density

One concern in trials using tenofovir as post-exposure prophylaxis has been that all antiretrovirals seem to cause a transient loss in bone mineral density, but that this seems to be larger and in some studies persistent in people taking tenofovir.
A study of 2045 iPrEx participants using DEXA scans (Mulligan) found that bone mineral density (BMD) scores at trial recruitment were already lower than would have been expected in men of the same age. Twelve per cent of participants had a ‘Z score’ for BMD in their spine of more than minus two, meaning that they fell into the lowest 5% of BMD values for an average population. BMD scores in the hip were also lower than expected.
During the trial BMD declined approximately 0.6% further in the spine (though not in the hip) in people taking Truvada but did not decline in subjects taking placebo, during the first six months. In the minority of subjects so far measured out to 18 months it declined by 1%. Nine per cent of subjects on Truvada had a loss of more than 5% in their spinal BMD compared with 4% on placebo.
This 1% average decline compares with an average 2 to 4% decline in patients taking tenofovir for treatment. There appeared to be no clinical effects, but at present we only have data on most subjects for the first six months, so it is not known if this bone loss is progressive or will stabilise.
Another study of BMD was presented from a different PrEP study: the safety trial of tenofovir PrEP in 400 US gay men which ended in July 2010 (Liu). This substudy only looked at the 200 participants from San Francisco. It found a loss of about 2% BMD in the neck of the hip bone over two years, though not in the spine.
This study also found lower-than-expected BMD in study entrants. It found than men using amphetamines were six times more likely to report low BMD at baseline and users of poppers 4.5 times as likely; conversely men who took vitamin D, calcium or multivitamins were 70% less likely to report low BMD.  

References

Grant R et al. Pre-exposure chemoprophylaxis for prevention of HIV among trans-women and MSM: iPrEx study. 18th Conference on Retroviruses and Opportunistic Infections, Boston, abstract 92, 2011.
Anderson P et al. Interpreting detection rates of intracellular FTC-TP and TFV-DP: the iPrEx trial. 18th Conference on Retroviruses and Opportunistic Infections, Boston, abstract 96LB, 2011. 
Amico R et al. Adherence indicators and PrEP drug levels in the iPrEx study. 18th Conference on Retroviruses and Opportunistic Infections, Boston, abstract 95LB, 2011.
Mulligan K et al. Effects of FTC/TDF on bone mineral density in seronegative men from 4 continents: DEXA results of the global iPrEx study. 18th Conference on Retroviruses and Opportunistic Infections, Boston, abstract 94LB, 2011.
Liu A et al. BMD loss in HIV men participating in a TDF PrEP clinical trial in San Francisco. 18th Conference on Retroviruses and Opportunistic Infections, Boston, abstract 93, 2011.

Abstracts and webcasts

You can view the abstracts from this research on the official conference website:
Abstract 92: www.retroconference.org/2011/Abstracts/42567.htm
Abstract 96LB: www.retroconference.org/2011/Abstracts/42612.htm
Abstract 95LB: www.retroconference.org/2011/Abstracts/42627.htm
Abstract 94LB: www.retroconference.org/2011/Abstracts/42550.htm
Abstract 93: www.retroconference.org/2011/Abstracts/40208.htm
You can also watch a webcast of the presentations made at this conference session, including the speakers Robert Grant, Peter Anderson, Rivet Amico, Kathleen Mulligan and Albert Liu.
Webcast from Advances in PrEP.
We rely on donations to continue our work to help people with HIV, support us today at: www.aidsmap.com/donate

jueves, 3 de marzo de 2011

LA INVESTIGACION EN SALUD Y LA EDUCACION EN SALUD PUBLICA EN EL ECUADOR

Estimados colegas aqui una visiçon sobre la investiogación en el Ecuador.
Saludos 
Dr. Carlos Erazo


Dr. Mario Paredes Suárez*
Dr. Ramiro López Pulles*
*Proceso de Ciencia y Tecnología en Salud (PCYT)
Ministerio de Salud Pública del Ecuador
1. INTRODUCCION
Al hablar de la investigación científica, del Desarrollo Tecnológico y de la Innovación, debemos
partir de una perspectiva particular cuando enfrentamos este aspecto entre países
industrializados y países en desarrollo, pues si bien es verdad se presenta como una
necesidad y urgencia común, las características en cada uno de ellos, son muy diferentes.
En 1977, durante la realización de la Asamblea Mundial de la Salud, la OPS/OMS, proclamó al
mundo uno de los objetivos más importantes, de Políticas Mundiales, a fin de mejorar la calidad
de atención a la Salud y de rescatar a un número muy importante de la comunidad mundial,
que se hallaba en circunstancias deplorables en su atención médica y en sus niveles de salud y
de vida. Esta proclama, “Salud Para Todos en el Año 2000", vino a transformarse en la meta
más ansiada por los países de mundo, en especial de aquellos pequeños, de economías
precarias, altamente dependientes y con índices alarmantes de salud.
En 1978, en Alma Ata, la misma OPS/OMS, con el objeto de operacionalizar el postulado
anterior, propuso la estrategia de “Atención Primaria" para facilitar la ejecución de programas
mínimos de atención y tratar de cubrir el enorme déficit que existía en ese entonces.
Posteriormente, en 1981, esta misma organización adoptó el Plan Para Latinoamérica, que
tenía por objetivo desarrollar y promocionar actividades en salud en los países en desarrollo y
que podría contribuir a alcanzar los objetivos de las propuestas anteriores. Uno de los
componentes más importantes de este Plan fue el relacionado con la Investigación Biomédica.
En el Ecuador, en el período 2001 y 2002 se establece la Política y la Ley del Sistema Nacional
de Salud, que marcaron tanto los principios generales como los aspectos jurídicos a la reforma
estructural del sector de la salud. Otro hecho constituye el inicio de actividades encaminadas a
la participación de los diferentes integrantes del Sistema Nacional de Salud y de la sociedad
civil que promovieron, en octubre del 2002, el Foro Nacional de Investigación en Salud y para
marzo del 2004, se instala la Comisión de Ciencia y Tecnología (COMCYT) del Consejo
Nacional de Salud (CONASA), con funciones específicas detalladas en el Reglamento a la Ley,
e integrada por todos los delegados de las instituciones que constituyen el Sistema Nacional de
Salud.
En cumplimiento de la legislación vigente en el Ecuador, el Ministerio de Salud Pública lidera la
Investigación y el Desarrollo Tecnológico en Salud, a través del Proceso de Ciencia y
Tecnología (PCYT); quien por expreso mandato y, a través de su Misión y Visión, debe normar,
organizar y controlar la Investigación en Salud, el Desarrollo Tecnológico del sector y la
aplicación de la Bioética en las actividades relacionadas.
Los soportes legales emanados de la Política Nacional de Ciencia y Tecnología del
FUNDACYT/SENACYT, la formulación de la Política Nacional de Investigación en Salud y los
Acuerdos respectivos acreditan estas atribuciones a este Proceso (PCYT).
No debemos olvidar que, la globalización ha rebasado los límites de la geoeconomía y la
geopolítica para introducirse en el pensamiento científico y, por ello, debemos adelantarnos a
los acontecimientos futuros y desarrollar acciones que destaquen la importancia de las alianzas
estratégicas con todos los sectores involucrados en el avance de la investigación, la ciencia y
la tecnología en salud.
Las actividades de la investigación, la ciencia y la tecnología no deben concentrarse a
proyectos de corto plazo. Debemos mirar con perspectiva lo que el conocimiento nos pone en
nuestras manos y, acorde a esta perspectiva, elaborar, proponer y desarrollar protocolos y
propuestas de mediano y largo plazo definiendo algunos elementos detonadores de esta visión,
asegurando que sus beneficios contribuirán a mejorar la calidad de vida y de salud de los
ecuatorianos.
En soporte a estos conceptos, el modelo de acción del Ministerio de Salud Pública en el campo
de la investigación en salud se enmarca en las recomendaciones de la OPS/OMS así como en
el cumplimiento de los objetivos y metas del Milenio, como compromiso universal.

Salud del adolescente / Cursos gratuitos

Dear Colleague:
We are pleased to present the third CDC Learning Connection Spotlight for 2011: Teen Heath at http://www.cdc.gov/learning/spotlight.html. This Spotlight provides learning products and resources to better prepare the public health community to promote safe and nurturing environments for teens to become healthy, productive adults.
Learning products featured in the Spotlight include the following:
Dating Matters: Understanding Teen Dating Violence Prevention
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  • Developed by the Centers for Disease Control and Prevention (CDC) in partnership with Liz Claiborne, Inc.
  • Provides an interactive resource center with access to additional dating violence information, links to curricula, strategies, and tools
Using Evidence for Public Health Decision Making: Violence Prevention Focused on Children and Youth
  • Summarizes the findings of the Task Force on Community Preventive Services
  • Reviews the effectiveness of violence prevention interventions focused on children and youth
Teen Health resources include
Share the Spotlight.
Teen Health eCard Thumbnail 
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Through the CDC Learning Connection, you can 
  • Access over 200 products in this growing collection of public health-related learning
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