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October 2002

Blacks Dying of AIDS Faster; Many in San Francisco Slow to Seek Care

Black AIDS patients in San Francisco are dying sooner than their white and Latino counterparts, despite the widespread availability of antiviral drugs, according to a new study. Among all racial and ethnic groups, the successful use of drug combinations such as AZT, 3TC and protease inhibitors dramatically cut AIDS deaths in the city since they became available in 1996. But African-American AIDS patients had a shorter survival time before the drugs arrived, a gap that has narrowed only slightly since then.

According to Department of Health epidemiologists, the most likely explanation is that African-American AIDS patients in the city are less likely -- for unexplained reasons -- to be taking the medications. In the three years before the widespread use of combination drugs, about 59 percent of white patients survived five years after diagnosis. For African-Americans in the city, the survival rate was only 49 percent -- a 10-point survival gap. In a four-year period after the drugs became available, the comparable survival rates were 79 percent and 71 percent, respectively, an 8-point gap. Survival rates for Latinos during the two periods were similar to those of whites. When the drugs first became widely available, 45 percent of white San Francisco AIDS patients took them, compared with 37 percent of Latino patients and only 27 percent of black patients.

Since 1996, the medicine gap has narrowed substantially: 79 percent of white and Latino AIDS patients take the combination pills, compared with 74 percent of black patients. Duane Poe, executive director of San Francisco's Black Coalition on AIDS, said black men with AIDS may have been less willing than white men to participate in studies of experimental AIDS drugs. Many still carry distrust over the infamous Tuskegee experiments. Poe noted that African-American AIDS patients in the city are more likely to be battling poverty, homelessness and lack of education than white patients. "It's not so much a race issue as a class issue," he said. McFarland said more research is needed to determine why usage rates of combination drug therapy differ and what steps need to be taken to close the survival gap. (San Francisco Chronicle, 06.27.02, Sabin Russell)


Majority in US Have Not Been Tested for HIV

Although nearly 750,000 cases of AIDS have been diagnosed since the US epidemic began two decades ago, most Americans have never been -- and do not want to be -- tested for HIV, according to a new poll published in AIDS Patient Care and STDs (2002;16:293-299). "Only 30 percent of adults in the United States have ever been tested for HIV after 20 years of [the] HIV epidemic," said study author Dr. Joseph N. Inungu of Central Michigan University in Mount Pleasant.

The study examined data on more than 32,000 US men and women collected during the 1998 National Health Interview Survey. In addition to answering questions about race, residence, educational achievement and marital status, the participants stated whether or not they had been tested for HIV, and if not, why. All were between ages 18 and 80, and nearly 70 percent were white. Sixty-six percent of those polled had never been tested for AIDS, and 58 percent said they did not want to be tested, although they could not identify any particular reason for their reluctance. While neither a fear of discrimination nor a lack of physician encouragement appeared to deter many from getting tested, Inungu observed that 38 percent simply did not believe they were at risk for contracting HIV.

Compared to those who had been tested, those Americans who had not been were more likely to be male, white, married, living outside of urban centers, and either age 18 to 24 or over 50. Those living in the Midwest, the region with the lowest number of HIV infections were also less likely to get an HIV test, while Hispanics, African-Americans and those currently single were more likely to want to get tested.

Inungu concluded that public health efforts to encourage Americans to obtain HIV tests have largely failed. The problem, he suggests, might be rooted in the narrow focus HIV education initiatives have placed on increasing test demand among young and urban adults, while neglecting older Americans and those in regions with lower infection rates. He suggested that voluntary testing be included as part of the routine primary health care offered to all patients. "The euphoria generated by the antiretroviral therapies has made some people in high-risk groups very complacent," Inungu said. (Reuters Health, 06.24.02, Alan Mozes)

HIV Develops Resistance to Experimental Drug

The experimental AIDS drug T-20, which researchers hope will benefit people whose HIV infections have become resistant to other medications, may itself sometimes cause HIV resistance to develop, suggests a new study in Antimicrobial Agents and Chemotherapy (2002;46:1896-1905). The resistance developed in a study of patients taking T-20 alone, not in combination with other medications. Recently, Roche Holding AG, which is developing the drug with Trimeris Inc., reported encouraging results of studies of T-20 used in combination with other AIDS drugs.

"Both studies indicate that T-20 significantly enhances the activity of HIV combination therapy," said Dr. Dani Bolognesi, CEO and chief scientific officer of Trimeris. The cases of HIV resistance developed in an early-phase trial designed to test the safety of the drug in humans, he said. That resistance was only in patients taking a lower dose than is being tested in later trials of T-20, which are ongoing. Resistant viruses have not developed in those studies, according to Bolognesi.

Unlike current AIDS drugs that target HIV once it has already entered cells, the fusion inhibitor T-20 works by keeping HIV from entering cells in the first place.

In the study, Dr. John C. Kappes and colleagues at the University of Alabama-Birmingham studied 16 HIV-positive patients. Patients took 3 mg, 10 mg, 30 mg or 100 mg of T-20 twice a day for two weeks. In patients taking the two lowest doses, there was no noticeable effect on the viral load. In all patients taking the highest dose, however, viral load dropped below detectable levels. Resistance developed in patients taking the 30 mg dose. These patients experienced some decline in viral load, though not as large as the drop seen in the 100 mg group. At the end of the study, though, the researchers detected HIV mutations in two of the four patients in the 30 mg group.

"Our study of patients receiving T-20 monotherapy provided the first evidence for the rapid emergence of clinical resistance to a novel class of entry inhibitors," Kappes said. "These findings are highly relevant to ongoing and future treatment strategies involving these agents," he said. (Reuters Health, 06.20.02, Merritt McKinney)

Evaluating the Risk of HIV Transmission Through Unprotected Orogenital Sex

The authors analyzed a cohort of heterosexual HIV-serodiscordant couples to evaluate the risk of transmission ascribed to unprotected orogenital intercourse. The possibility of HIV transmission through orogenital contacts has been described several times, from man to woman, as well as woman to man. A recent study found eight cases of probable orogenital transmission among 102 recently infected men who had had sex with men.

Between 1990 and June 2000, in a STD and HIV testing clinic in Madrid, the authors followed an open cohort of individuals who were initially seronegative for HIV and whose heterosexual steady partner had had a diagnosis of HIV infection confirmed. Each member of each couple was followed in the same clinic with regular six monthly examinations. Subjects were surveyed about each type of contact, whether protected or unprotected, as well as about ejaculations and accidents with condoms. Determination of antibodies to HIV was carried out for the member of the couple who was not initially infected. Individuals who showed any risk exposure to HIV other than to sex with the mentioned partner were excluded from the study.

A total of 135 seronegative individuals (110 women and 25 men) whose only risk exposure to HIV was unprotected orogenital sex with their infected partner, participated in the study. For the 110 HIV-seronegative women whose partner was an infected man, 179 person-years of follow-up were taken into account. Of these women, 96 performed fellatio without a condom, which gave an estimated total of 8,965 unprotected fellatios, of which 3,060 (34 percent) were with ejaculation in the oral cavity. Ninety-eight infected men carried out unprotected cunnilingus on the uninfected woman with an estimate of 8,656 practices of this type. Among the HIV-infected members of the couples, 8.1 percent had been diagnosed with AIDS and 15.6 percent had a CD4 cell count lower than 200 x 106/l. For 60 individuals an HIV-1-RNA quantification was available, and six of them presented with greater than 10,000 copies/ml. Of the 135 initially infected partners, 39 percent received antiretroviral therapy during the follow-up. The authors reported registering 210 person-years of follow-up with participants.

While a number of women presented with vaginal infections, the 135 individuals, "who had had over 19,000 unprotected orogenital contacts with their HIV-infected partner," presented without a single case of seroconversion to HIV. According to the authors, "this seems to point to a very low probability of HIV transmission related to this practice, when other risk exposures are excluded." (AIDS, 06.14.02, Vol. 16; No. 9: P. 1296-97, Jorge del Romero et al.)

AMA Unit Says "No" to Mandatory HIV Testing of Pregnant Women

The American Medical Association reversed its 5-year-old policy that HIV testing should be mandatory for pregnant women. Instead, during the interim meeting of the AMA House of Delegates in San Francisco, the representatives of the 290,000-member organization revised the recommendations, substituting "universal" testing for HIV status. "We believe the data show a clear benefit to universal HIV testing," said Mohammed Khan, M.D., a member of the AMA's Council on Scientific Affairs, from Ann Arbor, Mich. "We believe it prevents the problem in the mandatory approach to testing in which some women may decline prenatal care in order to avoid mandatory testing. If this is enacted we believe this type of approach will reduce further the risk of HIV transmission."

The legislative body of the AMA without objection approved the change in the policy. The change in position moves the AMA in line with other medical organizations, including the American College of Obstetricians and Gynecologists (ACOG), which have shied away from making the testing a mandatory recommendation. The new policy states: "That there should be universal HIV testing of all pregnant women with notification of the right of refusal as a routine component of prenatal care." Paul Gluck, M.D., of Miami, representing ACOG at the AMA meeting, said "This excellent academic, scholarly report balances privacy, ethical concerns about autonomy and self-determination, public health concerns and individual health. We think this approach has been working and will continue to work and will provide universal screening for HIV in our pregnant population." (AIDS, 06.14.02, Vol.16; No. 09: P. N5-N6)

AIDS and HIV-Associated Cancer: Antiretroviral Therapy Improves Survival

Potent antiretroviral therapy improves outcomes for patients suffering from malignancies associated with HIV infection, US researchers report. Dr. Henry K. Tam and colleagues at the University of California-Los Angeles, Johns Hopkins University, Northwestern University, Howard Brown Health Center, and the University of Pittsburgh evaluated the effects of highly active antiretroviral therapy (HAART) on survival rates for HIV patients with Kaposi's sarcoma (KS) or non-Hodgkin's lymphoma (NHL).

Even when treatment was delayed until diagnosis of these HIV-associated cancers, survival rates rose significantly in patients who received HAART. The researchers reviewed data from 387 male HIV patients diagnosed with KS or NHL between 1990 and 1999. All the patients were enrolled in the Multicenter AIDS Cohort Study.

Roughly 14 percent received HAART: Many studied patients were diagnosed before the advent of antiretroviral treatments. "The use of HAART prolongs overall survival among HIV-positive men diagnosed with KS and NHL," Tam and colleagues concluded. "HAART appears to be effective in improving survival even when initiated after the diagnosis of NHL and KS." The researchers reported that the mortality risk after HAART dropped by 84 percent for NHL patients and 81 percent for KS patients. (Cancer Weekly, 06.18.02, Michael Greer)

Needle Access Difficult in Bronx

As part of a New York Academy of Medicine study, monitors visited about 90 pharmacies participating in the state's Expanded Syringe Access Demonstration Program, whose goal is to curb the spread of disease among intravenous drug users. Overall, monitors were able to buy syringes at 69 percent of the pharmacies citywide. But in the Bronx, monitors came away empty-handed from 67 percent of the pharmacies. By comparison, monitors were unable to get syringes at 33 percent of pharmacies in Queens, 28 percent in Brooklyn, 16 percent in Manhattan and 11 percent in Staten Island. Even when they could buy needles, monitors often first had to give personal information or answer probing questions about the purchase.

"I was very concerned by it. It's certainly not because there's no need. There's a very strong need for this item," said study director Dr. Ruth Finkelstein. "The Bronx has a very large number of active [drug] injectors and associated HIV infection."

As of mid-March, 2,458 health providers and pharmacies had registered with the syringe program, said Finkelstein, director of the Academy's Office of Special Populations. Of those, 867 were in the five boroughs of New York City. The study found that "syringe monitors were only able to successfully buy syringes, without inappropriate questions and with a safety insert and disposal information upon request, in 7 percent of the pharmacy visits."

A Health Department spokesperson said the state has already undertaken training programs with pharmacies and community groups, adding, "Studies by other groups will certainly be considered. If they point out areas that can be addressed immediately, we will do that."

According to Assemblyman Richard Gottfried (D-Manhattan), who sponsored the syringe law, "In New York state, most HIV transmission is from, or has been from, needle sharing or people having sex with someone infected by needle sharing. The reason addicts share needles is simply because needles were only available on the black market at black market prices." (New York Daily News, 06.20.02, Celeste Katz)

Experts See Dangerous Trend in Use of Viagra With "Party Pills"

In research by Dr. Jeffrey Klausner, chief of the San Francisco Department of Public Health, nearly a third of gay men surveyed at STD clinics said they were using the anti-impotence drug Viagra, often in combination with illegal drugs that tend to encourage risky behavior. Health experts say Viagra alone seems to pose no real danger to men who use it recreationally even if they do not need it to get erections. But Klausner said that people who use it to offset the impotence effect of "party drugs" like Ecstasy and crystal methamphetamine also acknowledged having unprotected sex with more partners. Viagra can be deadly if used with amyl nitrite ("poppers"), which some gay men take to facilitate sex.

Klausner's study in the journal AIDS (2002;16;10), focuses on a particularly high-risk group of men in San Francisco, but health experts say other cities have similar subcultures where gay and straight men combine Viagra with other drugs. At the CDC, experts were already concerned about rising rates of STDs among gays and other young people who have become complacent about condom use now that AIDS drugs are helping infected people live longer. Viagra needs to be studied more closely as another possible factor in sexually reckless behavior, said Dr. Ronald Valdiserri, the CDC's deputy chief of STDs. "I see the Viagra story as a sort of subplot in all of this. We take all of this very seriously," he said.

Klausner's survey found that uninfected Viagra users were twice as likely to have unprotected sex with someone who is or might be HIV-infected, compared to those not taking Viagra. Viagra users also reported more partners than non-users. Klausner and other health officials want stronger warning labels on Viagra urging users to wear condoms. Pfizer, the drug's maker, says Viagra labels and ads clearly say the drug does not protect against STDs. The Food and Drug Administration is reviewing Klausner's complaints about Pfizer's labels. (Associated Press, 06.20.02, Kim Curtis, Margie Mason)

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This article was provided by Body Positive. It is a part of the publication Body Positive.