Estimados colegas, aqui encontraremos un curso básico de Epi Info en español con videos muy claro y útil.
Aqui estan los links.
Parte I. http://www.cure4kids.org/private/lectures/ppt2059/zip_C4K-2046-0MX-Dise_Creacion_Datos_I.zip/player.html
Parte II. http://www.cure4kids.org/private/lectures/ppt2060/zip_C4K-2047-0MX-Dise_Creacion_Datos_II.zip/player.html
Parte III. http://www.cure4kids.org/private/lectures/ppt2057/zip_C4K-2044-0MX-Codigo_check.zip/player.html
Parte IV. http://www.cure4kids.org/private/lectures/ppt2061/zip_C4K-2048-0MX_Grabar_Datos%202.zip/player.html
Parte V. http://www.cure4kids.org/private/lectures/ppt2062/zip_C4K-2049-0MX-Analyze_Data.zip/player.html
Parte VI. http://www.cure4kids.org/private/lectures/ppt2063/zip_C4K-2050-0MX-Importar_Exportar.zip/player.html
Parte VII. http://www.cure4kids.org/private/lectures/ppt2064/zip_C4K-2051-0MX_Generando_Informe.zip/player.html
Pueden obtener el curso y bajarse los documentos en esta dirección.
http://www.phconnect.org/group/epiinfo/forum/topics/epi-info-online-tutorials-in
Este link le llevará a una presentación del curso básico de EPI INFO.
Saludos
Dr. Carlos Erazo
domingo, 10 de abril de 2011
viernes, 8 de abril de 2011
HIV and injecting drug use: a global call for action
HIV and injecting drug use: a global call for action When world leaders meet in New York at the UN High-Level Meeting on AIDS (June 8–10, 2011), they will review the past decade’s progress and chart the future course of the global HIV response. There are some advances to celebrate, with global HIV incidence falling and access to treatment improving. But there are also unmitigated failures to be addressed moving forward. As a Lancet Series emphasised last year, people who inject drugs have been left behind in global eff orts to scale up access to HIV prevention, treatment, care, and support. Their needs have been neglected, and their rights have been ignored, and, in many cases, horribly
violated as governments have chosen to pursue punitive, disproportionate drug laws instead of evidence-based health strategies to address drug-related harm. The June meeting represents a unique opportunity to correct these injustices. A new document—the Beirut Declaration on HIV and Injecting Drug Use: A Global Call for Action—released at the 22nd International Harm Reduction Conference, Beirut, Lebanon (April 3–7, 2011), sets out how the international community has failed people who inject drugs and the actions now required by governments. Crucially, evidence-based programmes (needle and syringe exchange programmes, opioid substitution, and antiretroviral treatment) targeting the 16 million people who inject drugs worldwide need to be fi nanced, implemented, and scaled up across all settings to prevent and treat HIV infection. Ineff ective drug policies also need to end, funding for harm reduction needs to be vastly increased, and vulnerable groups who inject drugs (including women, young people, and people in prison) need access to integrated health and harm-reduction services. These actions should be explicitly included in the new global declaration on
HIV/AIDS that will be drafted at the June meeting with measurable targets to hold governments accountable. Misplaced moral judgments have underpinned the neglect of people who inject drugs in the global HIV response. Yet it is wholly immoral to let people become infected with HIV or die when evidence-based interventions exist to prevent these outcomes. A bold and humane response is needed from governments at the June meeting and beyond. Millions of lives are at stake.
violated as governments have chosen to pursue punitive, disproportionate drug laws instead of evidence-based health strategies to address drug-related harm. The June meeting represents a unique opportunity to correct these injustices. A new document—the Beirut Declaration on HIV and Injecting Drug Use: A Global Call for Action—released at the 22nd International Harm Reduction Conference, Beirut, Lebanon (April 3–7, 2011), sets out how the international community has failed people who inject drugs and the actions now required by governments. Crucially, evidence-based programmes (needle and syringe exchange programmes, opioid substitution, and antiretroviral treatment) targeting the 16 million people who inject drugs worldwide need to be fi nanced, implemented, and scaled up across all settings to prevent and treat HIV infection. Ineff ective drug policies also need to end, funding for harm reduction needs to be vastly increased, and vulnerable groups who inject drugs (including women, young people, and people in prison) need access to integrated health and harm-reduction services. These actions should be explicitly included in the new global declaration on
HIV/AIDS that will be drafted at the June meeting with measurable targets to hold governments accountable. Misplaced moral judgments have underpinned the neglect of people who inject drugs in the global HIV response. Yet it is wholly immoral to let people become infected with HIV or die when evidence-based interventions exist to prevent these outcomes. A bold and humane response is needed from governments at the June meeting and beyond. Millions of lives are at stake.
Health of lesbian, gay, bisexual, and transgender populations
The Lancet Institute of Medicine
http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673611604820.pdf
Health of lesbian, gay, bisexual, and transgender populations The past 20 years have seen dramatically increased visibil ity of people who are lesbian, gay, bisexual, and transgendered (LGBT) in US society. This diverse and vibrant group are now active and welcome members of many communities
across the country and are well recognised and praised for being a major force in the positive global response to the HIV/AIDS epidemic. Substantial achievements to advance their health status, such as the established partnership between LGBT organisations and foundations or corporations to access funding to address the HIV/AIDS epidemic, have been achieved. Yet, there is still a great deal to learn. Basic demographic data are lacking for LGBT populations in the USA. Many health practitioners are not well informed about how to care for LGBT populations, or about what constitutes healthy development of LGBT adolescents, and they do not understand enough about the development of sexual orientation, diverse gender identities, LGBT families, or the eff ect of stigma and discrimination on health. To develop a more complete picture of the health status of people who are LGBT and to identify research gaps, the Institute of Medicine (IOM) released The Health of Lesbian,
Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Using a life-course perspective, the report examines the health status of these populations in three stages: childhood and adolescence, early and middle adulthood, and later adulthood. The IOM fi nds that, although these populations share the full range of health risks with the rest of society, they are also exposed to a unique yet poorly understood set of additional threats.
For instance, compared with their heterosexual peers, members of the LGBT community are at increased risk of suicide, depression, harassment, and victimisation, and they may have higher rates of smoking and alcohol use. It is worth noting that for teenage lesbian and bisexual girls, pregnancy rates may be higher than those of heterosexual girls. Girls may deliberately attempt to get pregnant in an eff ort to defi ne and strengthen an identity for themselves. In early and middle adulthood, lesbians and bisexual women may also be at higher risk for breast cancer and for obesity, while men who have sex with men, especially those who are HIV-positive, are at increased risk for anal cancer. Meanwhile, in some studies, lesbians were signifi cantly more likely than heterosexual women to receive a diagnosis of heart disease. In later adulthood, LGBT are less likely to have a partner or children to provide them with health and social care, resulting in their greater dependence on friends, caregivers, and LGBT organisations. There has been clinical concern about rates of diabetes, ovarian disease, and stroke among transgender older people potentially as a result of longterm hormone treatments. Furthermore, HIV/AIDS re mains a crucial health issue for gay or bisexual men, transgender women, and LGBT who inject drugs. Additionally, people who are LGBT face barriers to equitable health services in
the USA, such as diffi culty in obtaining health insurance, fear of discrimination from providers, and a shortage of providers who are well trained in their health needs. When addressing health issues for people who are LGBT, researchers are confronted with many challenges, one of which is a lack of systematically or accurately collected data. The LGBT community make up a sometimes hidden minority of the population and it is hard to recruit suffi cient numbers to studies to yield meaningful results. Moreover, the LGBT acronym does not represent a homogeneous group, and it can be
diffi cult to defi ne and measure sexual orientation and gender identity. Additionally, some LGBT individuals are reluctant to disclose details about themselve s and take part in research, because research topics may be sensitive and can be perceived as intruding on privacy. The availability of high-quality evidence is central to improvement of knowledge. The report calls for a research agenda to collect data, examine appropriate method ology, train researchers, and develop policy on
research participation, provided that privacy concerns can be satisfactorily addressed. It also emphasises several priority research areas—demography, social infl uences, health-care inequalities, and intervention research. The IOM report is groundbreaking. Not only does it re view the LGBT community’s health needs comprehen sive ly, but it also brings a sea change in establishing edu cation al and research guidance for LGBT health. Actions in response to the report are already underway,
such as integration of LGBT health education into medical school curricula. The full participation of the LGBT community in their health and wellbeing is crucial. Above all, scientifi c and clinical engagement is essential to improve awareness and understanding of LGBT health issues, and to incorporate them into mainstream health care. The Lancet Institute of Medicine
http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673611604820.pdf
Health of lesbian, gay, bisexual, and transgender populations The past 20 years have seen dramatically increased visibil ity of people who are lesbian, gay, bisexual, and transgendered (LGBT) in US society. This diverse and vibrant group are now active and welcome members of many communities
across the country and are well recognised and praised for being a major force in the positive global response to the HIV/AIDS epidemic. Substantial achievements to advance their health status, such as the established partnership between LGBT organisations and foundations or corporations to access funding to address the HIV/AIDS epidemic, have been achieved. Yet, there is still a great deal to learn. Basic demographic data are lacking for LGBT populations in the USA. Many health practitioners are not well informed about how to care for LGBT populations, or about what constitutes healthy development of LGBT adolescents, and they do not understand enough about the development of sexual orientation, diverse gender identities, LGBT families, or the eff ect of stigma and discrimination on health. To develop a more complete picture of the health status of people who are LGBT and to identify research gaps, the Institute of Medicine (IOM) released The Health of Lesbian,
Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Using a life-course perspective, the report examines the health status of these populations in three stages: childhood and adolescence, early and middle adulthood, and later adulthood. The IOM fi nds that, although these populations share the full range of health risks with the rest of society, they are also exposed to a unique yet poorly understood set of additional threats.
For instance, compared with their heterosexual peers, members of the LGBT community are at increased risk of suicide, depression, harassment, and victimisation, and they may have higher rates of smoking and alcohol use. It is worth noting that for teenage lesbian and bisexual girls, pregnancy rates may be higher than those of heterosexual girls. Girls may deliberately attempt to get pregnant in an eff ort to defi ne and strengthen an identity for themselves. In early and middle adulthood, lesbians and bisexual women may also be at higher risk for breast cancer and for obesity, while men who have sex with men, especially those who are HIV-positive, are at increased risk for anal cancer. Meanwhile, in some studies, lesbians were signifi cantly more likely than heterosexual women to receive a diagnosis of heart disease. In later adulthood, LGBT are less likely to have a partner or children to provide them with health and social care, resulting in their greater dependence on friends, caregivers, and LGBT organisations. There has been clinical concern about rates of diabetes, ovarian disease, and stroke among transgender older people potentially as a result of longterm hormone treatments. Furthermore, HIV/AIDS re mains a crucial health issue for gay or bisexual men, transgender women, and LGBT who inject drugs. Additionally, people who are LGBT face barriers to equitable health services in
the USA, such as diffi culty in obtaining health insurance, fear of discrimination from providers, and a shortage of providers who are well trained in their health needs. When addressing health issues for people who are LGBT, researchers are confronted with many challenges, one of which is a lack of systematically or accurately collected data. The LGBT community make up a sometimes hidden minority of the population and it is hard to recruit suffi cient numbers to studies to yield meaningful results. Moreover, the LGBT acronym does not represent a homogeneous group, and it can be
diffi cult to defi ne and measure sexual orientation and gender identity. Additionally, some LGBT individuals are reluctant to disclose details about themselve s and take part in research, because research topics may be sensitive and can be perceived as intruding on privacy. The availability of high-quality evidence is central to improvement of knowledge. The report calls for a research agenda to collect data, examine appropriate method ology, train researchers, and develop policy on
research participation, provided that privacy concerns can be satisfactorily addressed. It also emphasises several priority research areas—demography, social infl uences, health-care inequalities, and intervention research. The IOM report is groundbreaking. Not only does it re view the LGBT community’s health needs comprehen sive ly, but it also brings a sea change in establishing edu cation al and research guidance for LGBT health. Actions in response to the report are already underway,
such as integration of LGBT health education into medical school curricula. The full participation of the LGBT community in their health and wellbeing is crucial. Above all, scientifi c and clinical engagement is essential to improve awareness and understanding of LGBT health issues, and to incorporate them into mainstream health care. The Lancet Institute of Medicine
HHS Action Plan to Reduce Racial and Ethnic Health Disparities
Estimados colegas , este es el enalce para poder bajar el pdf de los planes para disminuir la desigualdad en salud basados en etnicidad y raza.
http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf
Saludos
Dr. Carlos Erazo
http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf
Saludos
Dr. Carlos Erazo
Approaching 30 Years of HIV/AIDS in the United States
April 08, 2011
By Ronald Valdiserri, M.D., M.P.H., Deputy Assistant Secretary for Health, Infectious Diseases, U.S. Department of Health and Human Services
In less than two months, we will mark the 30th anniversary of the first reported cases of what we now know as AIDS. In June 1981, the Centers for Disease Control and Prevention (CDC) reported a rare form of pneumonia diagnosed in five, previously healthy, gay men from Los Angeles. The report raised concerns that these five men had been exposed to something that caused their profound immune suppression. Now we know that their disease resulted from infection with HIV.
As we mark this significant milestone, we solemnly mourn the more than 600,000 Americans who have lost their lives to HIV disease. But we also honor, with pride, the men, women, and young people who have made important contributions to 30 years of fighting the HIV/AIDS epidemic in the United States and around the world. And certainly we celebrate the substantial advances in prevention, diagnosis and treatment that have been made in the past three decades. Although our journey hasn’t finished, we’ve come a very long way since those early days when so much was unknown about this deadly new disease.
Perhaps, most importantly, this observance will prompt each of us to consider how we can extend and enhance our individual and collective responses to the epidemic so that it does not persist for another 30 years. For the first time we have a National HIV/AIDS Strategy (NHAS) that all of us can use as a game-plan to better focus and coordinate our individual and organizational efforts. The Strategy was informed by our 30 years of experience with HIV/AIDS. Achieving its goals — reducing new HIV infections, increasing access to HIV care, improving health outcomes for people living with HIV, and reducing HIV-related health disparities — requires the active participation of all sectors of society. This includes not only local, state, tribal and federal governments, but also businesses, faith communities, philanthropy, the scientific and medical communities, educational institutions, people living with HIV, and many others.
Dr. Ronald Valdiserri
As we mark this significant milestone, we solemnly mourn the more than 600,000 Americans who have lost their lives to HIV disease. But we also honor, with pride, the men, women, and young people who have made important contributions to 30 years of fighting the HIV/AIDS epidemic in the United States and around the world. And certainly we celebrate the substantial advances in prevention, diagnosis and treatment that have been made in the past three decades. Although our journey hasn’t finished, we’ve come a very long way since those early days when so much was unknown about this deadly new disease.
Perhaps, most importantly, this observance will prompt each of us to consider how we can extend and enhance our individual and collective responses to the epidemic so that it does not persist for another 30 years. For the first time we have a National HIV/AIDS Strategy (NHAS) that all of us can use as a game-plan to better focus and coordinate our individual and organizational efforts. The Strategy was informed by our 30 years of experience with HIV/AIDS. Achieving its goals — reducing new HIV infections, increasing access to HIV care, improving health outcomes for people living with HIV, and reducing HIV-related health disparities — requires the active participation of all sectors of society. This includes not only local, state, tribal and federal governments, but also businesses, faith communities, philanthropy, the scientific and medical communities, educational institutions, people living with HIV, and many others.
If you have not yet had the opportunity to do so, I encourage you to read the Strategy and other information about its implementation available on AIDS.gov. Being familiar with the details of the Strategy will provide you with an even stronger foundation for engaging in efforts to enhance the HIV prevention, care and treatment, and stigma reduction activities that may be underway in your community. And if these efforts are not taking place in your community, the Strategy can suggest principles and priorities against which to assess current activities as well as opportunities to bring together new partners to help make that happen. A number of activities are being planned in recognition of this 30-year milestone. Shortly, AIDS.gov will post a page so you can follow the commemorative activities planned by various Federal government agencies.
After 30 years of HIV/AIDS, we need to recognize how far we have come but, at the same time, continue to commit ourselves to accomplishing what remains to be done. Then, we will truly achieve the vision of the NHAS:
After 30 years of HIV/AIDS, we need to recognize how far we have come but, at the same time, continue to commit ourselves to accomplishing what remains to be done. Then, we will truly achieve the vision of the NHAS:
“The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”
jueves, 7 de abril de 2011
High-Grade AIN Among HIV-Infected Men Who Have Sex with Men
In a 3-year prospective study, the cumulative incidence of high-grade anal intraepithelial neoplasia was 37% among HIV-infected MSM receiving ART.
The incidence of anal cancer has been increasing since the introduction of potent combination antiretroviral therapy (ART), but the reasons are unclear. In the present study, researchers evaluated the incidence of high-grade anal intraepithelial neoplasia (AIN) among 247 HIV-infected men who have sex with men (MSM) who were either initiating or already receiving potent ART. Participants underwent anal cytological analysis and high-resolution anoscopy (HRA) at baseline and then every 6 months to 1 year for 3 years.
During follow-up, 17% of participants had high-grade squamous intraepithelial lesions at least once, and 54% of participants had high-grade AIN (AIN2/3) at least once. In two men (1% overall), the condition progressed to invasive anal cancer. At 3 years, the cumulative incidence of high-grade AIN was 37%, and the progression rate from a lesser abnormality at baseline was 12.8 new cases per 1000 person-months. In a multivariate analysis, several factors were significantly associated with high-grade AIN: age 
40, CD4 count <50 cells/mm3 before ART initiation, and infection with human papillomavirus (HPV) type 16 or 18. Treatment with the same ART regimen for at least 4 years was associated with a reduced risk for high-grade AIN.
40, CD4 count <50 cells/mm3 before ART initiation, and infection with human papillomavirus (HPV) type 16 or 18. Treatment with the same ART regimen for at least 4 years was associated with a reduced risk for high-grade AIN.Comment: Although this study was small, it furthers our understanding of the risk for progression of AIN among HIV-infected MSM in the current treatment era. The incidence of new high-grade AIN may have been overestimated if lesions were missed on initial screening. Nevertheless, the data support the need for aggressive screening for AIN in the routine care of individuals who have engaged in receptive anal sex — and the aggressive monitoring of AIN when it is discovered. Although ART may provide some benefit in terms of reducing the risk for progression of AIN, the effect is not overwhelming. What we do not yet know is whether early detection and treatment of AIN in the ART era confers a reduction in the incidence of invasive cancer or improves survival.
Published in Journal Watch HIV/AIDS Clinical Care March 28, 2011
miércoles, 6 de abril de 2011
En breve colocaremos más información para su apoyo
Estimados colegas, esta semana se subirán artículos nuevos relacionados con el tema.
Gracias por su paciencia
Dr. Carlos Erazo
Gracias por su paciencia
Dr. Carlos Erazo
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.
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
Comentarios - 0La 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.
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, 201111 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, MDChief, 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 RoundsShane Joiner, Communication Manager, Public Health Grand Rounds
Additional Resources:
TB & HIV Fact Sheets: TB and HIV Coinfectionjueves, 10 de marzo de 2011
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
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
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.
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.
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);273-275Premastication (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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Taylor DN, Blaser MJ. The epidemiology of Helicobacter pylori infection. Epidemiol Rev 1991;13:42--59.
- 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.
- 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.
* Additional information available at http://www.cdc.gov/hiv/surveillance/resources/reports/2008report/index.htm.
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