MAPA DE LA SITUACION DEL VIH-SIDA EN ECUADOR 2010

ESTIMADOS COLEGAS, A LA DERECHA DE SU PANTALLA ENCONTRARAN EL LINK DEL MAPA HACIENDO CLICK SOBRE LA IMAGEN, EN ESTA SE HAN  REFERENCIADO DATOS POR CADA PROVINCIA SOBRE EL MAPA, AL DAR CLICK EN LOS GLOBOS , PODRAN VER LA INFORMACION COLOCADA EN CADA UNA DE LAS PROVINCIAS.

ESTAREMOS HACIENDO USO DE LA TECNOLOGIA DISPONIBLE PARA MANTENERLOS INFORMADOS, COMO FUE NUESTRO COMPROMISO.

SALUDOS.

DR. CARLOS ERAZO

ALGUNOS DATOS INTERESANTES SOBRE EL VIH

LOS CONDONES MASCULINOS SON EFECTIVOS PARA DISMINUIR EL RIESGO DE LA INFECCIÒN DEL VIRUS EN UN 80% A 95% .
LOS CONDONES FEMENINOS SON EFECTIVOS PARA DISMINUIR EOL RIESGO DE LA INFECCIÓN DEL VIRUS EN UN 94% A 97%.

FUENTE: THE SANFORD GUIDE TO HIV/AIDS THERAPY 2010.

SALUDOS

DR. CARLOS ERAZO

HIV Therapy Dramatically Cuts Transmission in Heterosexual Pairs

"By Michael Smith, North American Correspondent, MedPage Today Published: May 12, 2011

Triple-drug therapy dramatically reduced transmission of HIV in heterosexual couples when one partner is infected and the other is not, results of a randomized trial showed.
Treating the infected partner in these discordant couples reduced transmission by 96%, compared with no treatment, according to Myron Cohen, MD, of the University of North Carolina Chapel Hill, and colleagues.
The $73 million trial had been slated to finish in 2015 but was stopped early after those clear-cut results were found by the study's data safety monitoring board during a planned interim review.
A series of mathematical models and observational studies have suggested that treatment of HIV can reduce transmission, and other studies have suggested that anti-HIV drugs might be used as prophylaxis.
But this is the "first, rather dramatic, randomized trial in discordant couples," according to Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, one of the sponsors of the so-called HPTN 052 trial.
It "nails the concept down rather nicely," he said in a telephone media conference.
Outside experts hailed the trial as a giant step forward.

"This study is another milestone in the history of HIV," said John Bartlett, MD, of Johns Hopkins. "The concept of treatment for prevention is proven."

"Patients can take the drugs for their own health and for public health," Bartlett added in an email to ABC News/MedPage Today.

The findings have the potential to transform approaches to the treatment and prevention of HIV," according to Mark Kline, MD, of Baylor College of Medicine in Houston.

Kline noted in an email to ABC News/MedPage Today that a trial in the mid-1990s showed that administering a single anti-HIV drug to pregnant women could prevent mother-to-child transmission of the virus.

That finding had "an immediate and direct impact on public health policies" and led many experts to think that treatment might prevent infection in other settings, he said.

"Now, we have conclusive evidence from a prospective, randomized treatment trial in support of that contention," Kline said.

Indeed, the findings "must serve as a clarion call" for expanded access to treatment, according to Mitchell Warren, executive director of the New York-based AIDS Vaccine Advocacy Coalition.
"We now have evidence from a randomized trial confirming what has been seen in observational settings: (antiretroviral) treatment is prevention," Warren told MedPage Today in an email.
The study, conducted by the HIV Prevention Trials Network, began in April 2005 and enrolled 1,763 couples, 97% of them heterosexual, in nine countries.
All the HIV-infected participants -- 890 men and 873 women -- had relatively intact immune systems, with CD4-positive T-cell counts between 350 and 550 per cubic millimeter and were not eligible at the time for HIV treatment based on their local guidelines.
They were randomly assigned to get immediate treatment or to wait until their CD4 counts fell to 250 or they had an AIDS-defining event.
All told, the review found 39 cases of HIV infection among the previously uninfected partners, and genetic analysis showed that 28 of those came from the infected partner. (Seven did not, and four are still being analyzed.)
But 27 of the linked infections occurred in the deferred treatment group and just one in the immediate therapy arm, a difference that was significant at P<0.0001.
All participants in the deferred treatment arm are now being offered triple-drug therapy regardless of their CD4 count, Cohen told reporters during the telephone media conference.
He said that the original plan for the study was to have homosexual couples included, but very few agreed to take part. For that reason, he said, it would be a "mistake" to assume this finding would apply to men who have sex with men.
Cohen added that the trial shows that even with a relatively intact immune system, transmission can occur. "You can't look at a high CD count and make the assumption that transmission is not going to occur," he said.
HIV transmission risk is linked to the amount of the virus in the blood, the so-called viral load, but many physicians will assume that if the CD4 count is relatively high, they can "let it go," Fauci said. The study investigators are currently analyzing viral load data from the trial, he said.
The treatment regimens used in the trial varied depending on the location of patients, Fauci said, with 11 different antiretroviral drugs employed in various combinations.
The researchers also found that 17 cases of extrapulmonary tuberculosis occurred in the HIV-infected partners in the deferred treatment arm and just three in the immediate treatment arm. The difference was significant at P=0.0013.
There were 23 deaths -- 10 in the immediate treatment group and 13 in the deferred treatment arm -- but the difference was not significant."


LINK:  http://www.medpagetoday.com/HIVAIDS/HIVAIDS/26442?utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&userid=188864

Early HIV Treatment Associated with Greatly Reduced Transmission to Partners

Estimados colegas , aqui les dejo el link para poder revisarlo:

http://www.niaid.nih.gov/news/newsreleases/2011/Pages/HPTN052.aspx

Saludos

Dr. Carlos Erazo

A 10-year study on early HIV treatment has been stopped prematurely after a monitoring board found convincing evidence that it "can have a major impact on reducing HIV transmission," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, in an NIH announcement Thursday.
Called HPTN 052, the international study was conducted primarily among some 1800 heterosexual couples. One partner in each couple was uninfected at entry. Infected partners were randomized either to immediate treatment with a three-drug antiretroviral regimen or to deferred treatment (until CD4 counts fell below 250 per cubic millimeter or an AIDS-related event occurred).
There were 28 new infections linked to partners, 27 of which occurred among the deferred-treatment group, giving a relative reduction in transmission of 96%.
Dr. Carlos del Rio of Journal Watch HIV/AIDS Clinical Care commented that the findings "prove once and for all that antiretroviral therapy not only is good for the individual but it is also good for society, as it reduces HIV transmission."

Findings Result from NIH-funded International Study

Men and women infected with HIV reduced the risk of transmitting the virus to their sexual partners by taking oral antiretroviral medicines when their immune systems were relatively healthy, according to findings from a large-scale clinical study sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.
The clinical trial, known as HPTN 052, was slated to end in 2015 but the findings are being released early as the result of a scheduled interim review of the study data by an independent data and safety monitoring board (DSMB). The DSMB concluded that it was clear that use of antiretrovirals by HIV-infected individuals with relatively healthier immune systems substantially reduced transmission to their partners. The results are the first from a major randomized clinical trial to indicate that treating an HIV-infected individual can reduce the risk of sexual transmission of HIV to an uninfected partner.
“Previous data about the potential value of antiretrovirals in making HIV-infected individuals less infectious to their sexual partners came largely from observational and epidemiological studies,” said NIAID Director Anthony S. Fauci, M.D. “This new finding convincingly demonstrates that treating the infected individual—and doing so sooner rather than later—can have a major impact on reducing HIV transmission.”
Led by study chair Myron Cohen, M.D., director of the Institute for Global Health and Infectious Diseases at the University of North Carolina at Chapel Hill, HPTN 052 began in April 2005 and enrolled 1,763 couples, all at least 18 years of age. The vast majority of the couples (97 percent) were heterosexual, which precludes any definitive conclusions about effectiveness in men who have sex with men. The study was conducted at 13 sites in Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand, the United States and Zimbabwe. The U.S. site collected only limited data because of difficulties enrolling participants into the study. However, data from one serodiscordant couple at the site was included in the DSMB’s analysis. At the time of enrollment, the HIV-infected partners (890 men, 873 women) had CD4+ T-cell levels—a key measure of immune system health—between 350 and 550 cells per cubic millimeter (mm³) within 60 days of entering the study. The HIV-uninfected partners had tested negative for the virus within 14 days of entering the study.
The investigators randomly assigned the couples to either one of two study groups. In the first group, the HIV-infected partner immediately began taking a combination of three antiretroviral drugs. In the second group (the deferred group), the HIV-infected partners began antiretroviral therapy when their CD4 counts fell below 250 cells/mm³ or an AIDS-related event, such as Pneumocystis pneumonia, occurred. Throughout the study, both groups received HIV-related care that included counseling on safe sex practices, free condoms, treatment for sexually transmitted infections, regular HIV testing, and frequent evaluation and treatment for any complications related to HIV infection. Each group received the same amount of care and counseling.
In its review, the DSMB found a total of 39 cases of HIV infection among the previously uninfected partners. Of those, 28 were linked through genetic analysis to the HIV-infected partner as the source of infection. Seven infections were not linked to the HIV-infected partner, and four infections are still undergoing analysis. Of the 28 linked infections, 27 infections occurred among the 877 couples in which the HIV-infected partner did not begin antiretroviral therapy immediately. Only one case of HIV infection occurred among those couples where the HIV-infected partner began immediate antiretroviral therapy. This finding was statistically significant and means that earlier initiation of antiretrovirals led to a 96 percent reduction in HIV transmission to the HIV-uninfected partner. The infections were confirmed by genetic analysis of viruses from both partners.
Additionally, 17 cases of extrapulmonary tuberculosis occurred in the HIV-infected partners in the deferred treatment arm compared with three cases in the immediate treatment arm, a statistically significant difference. There were also 23 deaths during the study. Ten occurred in the immediate treatment group and 13 in the deferred treatment group, a difference that did not reach statistical significance.
The study was designed to evaluate whether antiretroviral use by the HIV-infected individual reduced HIV transmission to the uninfected partner and potentially benefited the HIV-infected individual as well. Additionally, the study was designed to evaluate the optimal time for a person infected with HIV to initiate antiretrovirals in order to reduce HIV-related sickness and death. Based on their analysis, the DSMB recommended that the deferred study arm be discontinued and that the study participants be informed of the trial’s outcome.
“We want to thank the study participants for making such an important contribution in the fight against HIV/AIDS. We think that these results will be important to help improve both HIV treatment and prevention,” said Dr. Cohen.
Study participants are being informed of the results. Individuals who became HIV-infected during the course of the study were referred to local services for appropriate medical care and treatment. HIV-infected participants in the deferred treatment group will be offered antiretroviral therapy.  The study investigators will continue following the study participants for at least one year.
The study was conducted by the HIV Prevention Trials Network, which is largely funded by NIAID with additional funding from the National Institute on Drug Abuse and the National Institute of Mental Health, both part of the NIH. Additional support was provided by the NIAID-funded AIDS Clinical Trials Group. The antiretroviral drugs used in the study were made available by Abbott Laboratories, Boehringer Ingelheim Pharmaceuticals, Inc., Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline/Viiv Healthcare and Merck & Co., Inc.
The 11 HIV drugs that were used in various combinations included the following:

• atazanavir (300 mg once daily)
• didanosine (400 mg once daily)
• efavirenz (600 mg once daily)
• emtricitabine/tenofovir disoproxil fumarate (200 mg emtricitabine/300 mg tenofovir disoproxil fumarate once daily)
• lamivudine (300 mg once daily)
• lopinavir/ritonavir 800/200 mg once daily (QD) or lopinavir/ritonavir 400/100 mg twice daily (BID)
• nevirapine (200 mg taken once daily for 14 days followed by 200 mg taken twice daily)
• ritonavir (100 mg once daily, used only to boost atazanavir)
• stavudine (weight-dependent dosage)
• tenofovir disoproxil fumarate (300 mg once daily)
• zidovudine/lamivudine (150 mg lamivudine/300 mg zidovudine taken orally twice daily)

In an ongoing international clinical study called Strategic Timing of Antiretroviral Therapy, NIAID is examining the optimal time for asymptomatic HIV-infected individuals to begin antiretrovirals. For additional information about the HPTN 052 study, see the Questions and Answers. Visit the NIAID HIV/AIDS Web portal for more information about NIAID’s HIV/AIDS research.

Curso Básico de EPI INFO

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

GRFICOS EN EPI INFO(PORTUGUES)

ANALISIS DE DATOS CON EPI INFO (PORTUGUES) PARTE 1

ANALISIS DE DATOS CON EPI INFO (PORTUGUES)

USO DEL STATCALC EN EPI INFO (PORTUGUES)

ANALISIS CON EPI INFO CONSTRUYENDO TABLAS

ANALISIS INICIAL DE FRECUENCIA EN EPI INFO

CLASE DE EPI INFO INGRESANDO DATOS

PRIMERA CLASE DE EPI INFO

Instalación del EPIINFO desde el INTERNET

HIV and injecting drug use: a global call for action

 http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673611604753.pdf

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.

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

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

Approaching 30 Years of HIV/AIDS in the United States

PolicyApril 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

Dr. Ronald Valdiserri

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.

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:

“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.”

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.

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.

— Sonia Nagy Chimienti, MD

Published in Journal Watch HIV/AIDS Clinical Care March 28, 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

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.

— Mary E. Wilson, MD

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.

— Carlos del Rio, MD

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

— Paul E. Sax, MD

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

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La tuberculosis multirresistente aumenta en Europa

JANO.es y agencias · 21 Marzo 2011 09:15

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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.

— Rajesh T. Gandhi, MD

Published in Journal Watch HIV/AIDS Clinical Care March 21, 2011