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December 2004

New HIV Drug Guidelines

The US Department of Health and Human Services issued new recommendations on when HIV-infected persons should begin taking antiviral drugs.

The guidelines suggest that patients who have not previously taken HIV drugs and who have a viral load of more than 100,000 should consider starting drug therapy -- even if their T-cell count exceeds 350. The guidelines recommend that a patient with a T-cell count below 200, or who is experiencing AIDS-related symptoms, begin treatment regardless of his/her viral load.

Greg Gonsalves, director of treatment and prevention advocacy at Gay Men's Health Crisis, was a member of the federal panel that drafted the new recommendations. Patients as well as doctors will find the guidelines useful, he said.

When highly active antiretroviral therapy was introduced in 1996, the prevailing treatment practice was "hit early, hit hard," in the belief that starting HIV treatment upon diagnosis might eliminate the virus from the patient's body. "People have beaten a retreat from that and there is a much more conservative view, conservative in a good way, about when to start treatment," Gonsalves said. "They used to say that if people go above 55,000 viral load they should start treatment. Now, the bar for starting is a little higher. It is moving further away from hit early, hit hard."

The recommendations also discuss which drugs to take first and how to treat HIV-infected special populations -- including adolescents, injection drug users, and people co-infected with TB, hepatitis B or hepatitis C -- that may need help in complying with complex treatment regimens. Physicians and patients are urged to consider interactions among HIV drugs, and between HIV drugs and other drugs -- legal and illegal -- that patients may be taking. "Use the drugs when you need them. It's not like there is an unlimited supply of regimens people can take," Gonsalves said. HIV drugs are expensive, some have side effects, and HIV can become resistant to them over time. To access the full recommendations, visit (Gay City News, 11.04.04, Duncan Osborne)

Rare Infection Risk to Gay, Bisexual Men

The CDC alerted US doctors and clinics to be prepared to diagnose and treat gay and bisexual men who could be infected with the rare STD Lymphogranuloma venereum (LGV).

CDC issued the warning following reports of a recent outbreak of the disease among gay and bisexual men in the Netherlands, which uncovered 92 LGV cases dating back to 2003. The nation usually sees less than five cases a year. Belgium, France, Sweden and Britain have also reported infections. It is unknown whether a similar LGV surge affects the United States, because doctors are not required to report the infections to local health departments.

Caused by specific strains of the STD chlamydia, LGV is usually marked by genital ulcers, swollen lymph glands and flu-like symptoms. However, the men recently infected in the Netherlands developed gastrointestinal bleeding, inflammation of the rectum and colon and other problems not typically associated with LGV or other STDs.

LGV can be cured with a three-week course of antibiotics; however, it could be difficult to contain since it is uncommon in industrialized nations and is easily misdiagnosed. Control efforts could be complicated by some gay and bisexual men's high-risk sexual behavior. A large number of the men recently LGV-infected in the Netherlands had engaged in unprotected anal intercourse and taken part in sex parties in the year before getting sick, Dutch authorities found. Many were also HIV-infected.

"We expect it's a question of time before we see cases appearing here," said Dr. Stuart Berman, chief of epidemiology surveillance in CDC's division of STD prevention. "This is an early warning." (Reuters, 10.28.04, Paul Simao, 2004;53(42):985-988)

NJ Allows Needle Exchanges in 3 Cities

On Tuesday, Gov. James McGreevey signed an executive order authorizing the New Jersey Department of Health and Senior Services (DHSS) to oversee needle exchange programs in as many as three municipalities. The order covers only cities that have high HIV prevalence due to intravenous drug-use and that have ordinances allowing needle exchange programs. Camden and Atlantic City fit both criteria and are expected to make clean syringes available within weeks. A third city has not yet qualified.

To support his contention that HIV constitutes an emergency in New Jersey, McGreevey cited statistical evidence and referenced a study showing that HIV prevalence decreased by 29 percent in cities with needle exchanges, while prevalence increased by 5 percent in cities without the programs. "The evidence is incontrovertible. We have resisted the evidence at a high cost," he said. "The goal of the executive order is to demonstrate that the science works and to move forward," McGreevey said, even as he acknowledged the state's lack of political consensus on the issue.

McGreevey resigns his office on Nov. 15, when Senate President Richard J. Codey (D) will replace him. "We will review the order once we receive it," said State Attorney General Peter Harvey's office. Codey's office said he "wants to take a look at it and work with the other legislative leaders." Republican state Sens. Robert Singer and Thomas H. Kean questioned both McGreevey's declaration of an emergency and the constitutionality of the order. Sen. Ronald Rice (D) said he hoped the order would be quickly challenged. Needle-exchange programs are "a very effective gateway to engage drug users into health and social services, and into drug treatment," DHSS Commissioner Dr. Clifton Lacy said. "Regular visits to these syringe-exchange sites create an opportunity for referrals." A future governor can rescind the executive order. McGreevey's action leaves Delaware as the only state that bars needle-exchange programs and criminalizes possession of syringes without a prescription. (New York Times, 10.27.04, Damien Cave)

Health Officials Put Safer-Sex Message Online

In response to Internet-linked STD transmission, public and community agencies in many cities have begun to disseminate information on safe sex and STD prevention, screening and treatment on Internet sites where men go to arrange sexual encounters with other men.

Research suggests that men who meet through the Internet have a different profile than other gay men. A recent Los Angeles Department of Health study found two-thirds of men who met male sex partners online were HIV-positive; the men were 3.5 times as likely to have anonymous sex; and twice as likely to use injection drugs as men who met partners by other means. In a San Francisco survey of 91 men about their online activities, 39 percent reported having unprotected anal sex with partners they met online.

"The public health community has been reporting that the Internet surpasses bars and bathhouses as the most frequent place where sexual partners meet for the first time," said Dr. Ronald Valdiserri, deputy director of CDC's National Center for HIV, STD and TB Prevention.

Because of their relative novelty, Internet interventions that local agencies engage in often lack the guiding data on what works. Some health workers say the interventions are particularly useful for reaching rural areas, gay male youths and those who wish to remain anonymous. Online health promotions targeting gay men have included placing banner advertisements on sex-themed Web sites and offering online discussions concerning safe sex strategies and downloadable STD laboratory testing slips.

Government and private agencies in San Francisco have established the most varied online prevention approaches. One campaign the city backs encourages people to explicitly ask about partner HIV status and STDs, as well as anticipated sexual behavior. Terms like "clean" or "disease free" frequently used in Internet postings may be too vague for people to properly negotiate safety, said campaign organizers.

However, some private gay Web-site owners impose limits to the interventions. In some chat rooms, outreach workers can respond to questions only if members ask for advice. "If our customers feel as if their right to practice sex as they choose is infringed upon, it endangers the whole program," said Stephen Adelson, director of operations for Online Buddies, which operates the Manhunt site. (New York Times, 10.26.04, David Tuller)

Syphilis Through Oral Sex on the Rise

Syphilis is increasingly being transmitted through oral sex, according to a new CDC report published Friday. Mistaken in the belief that oral sex is safe sex, many people are unaware they can readily catch or transmit syphilis in this manner. Moreover, syphilitic sores in the mouth can increase the risk of HIV infection.

Over the period from 1998 to 2002, Dr. C. Ciesielski and colleagues from the Chicago Department of Public Health observed patterns of syphilis transmission change substantially. During the 1990s, syphilis occurred almost exclusively among heterosexuals, the researchers noted. But since 2001, men who have sex with men account for nearly 60 percent of people with syphilis.

To explain these findings, the researchers interviewed people who were infected with syphilis in 2000-2002. In nearly 14 percent of cases, oral sex was the subjects' only sexual exposure during the time they were infected; this mode was reported by 20 percent of MSM with syphilis, and 6-7 percent of heterosexuals. These figures did not include possible infection through oral sex when sexual intercourse also occurred.

People with syphilis in the mouth may not show any symptoms, or the sores could be mistaken for herpes or aphthous ulcers, the researchers noted. The syphilitic sores may carry high concentrations of the germ and be highly infectious.

"These data underscore the need for educating sexually active persons regarding the risk for syphilis transmission through oral sex," the researchers concluded. "Persons who are not in a long-term monogamous relationship and who engage in oral sex should use barrier protection (e.g., male condoms or other barrier methods) to reduce the risk for sexually transmitted disease (STD) transmission," the researchers advised. (Reuters Health, 10.21.04)

Under the Radar, HIV Worsens

Complacency about HIV/AIDS and a willingness to take risks that would have been unthinkable at the epidemic's height stem from the progress doctors and public health officials have made in controlling the disease, several experts said. "There's a perception that HIV or AIDS is no longer a big threat, so why bother" using condoms or abstaining from unprotected sex, said Ronald O. Valdiserri, head of HIV programs for CDC.

"There's a lot of misinformation," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. "It's troubling. ... We've been through a terrible period in our history and now we seem to be regressing back." One misperception is that antiretrovirals have eliminated AIDS as a major public health threat. "The drugs were rolled out without really thinking through their implications for risk behavior," said Thomas Coates, a UCLA infectious disease specialist. "There was a resurgence in high-risk behavior, and prevention was off the map."

Critics said CDC's change in strategy two years ago -- from a general educational campaign to one to teach people with HIV/AIDS how to avoid spreading it -- has lessened awareness of HIV/AIDS outside the most affected groups. However, CDC's strategy, which includes testing programs designed to help people find out their status, is a proven public health approach to infectious disease control. The Bush administration's promotion of abstinence over condom use does not focus on ways for sexually active people to prevent transmission, critics also said. The two strategy shifts have made it more difficult to reach young women and gay men who do not have the disease, said AIDS activists.

The number of people diagnosed annually with HIV has stayed at about 40,000 for several years. An additional 42,000 are diagnosed with AIDS each year. New HIV infections among gay men are rising, and the number of women with AIDS has quadrupled since 1986. In 2002, African Americans accounted for half of all new AIDS cases, and Latinos accounted for 20 percent, according to CDC. More than a quarter of AIDS cases are now women, many of them black or Latina. According to the National Center for Health Statistics, black females ages 15 and older are 15.5 times more likely to die of AIDS than whites. (Los Angeles Times, 10.16.04, Sharon Bernstein)

Housing Works Moves to Brooklyn "Epicenter"

Declaring that Brooklyn has become the "epicenter of the [HIV/AIDS] epidemic" in New York, Housing Works has relocated to the borough. Fourteen-year-old Housing Works is one of the city's largest HIV/AIDS advocacy groups; it helps homeless AIDS patients access housing and health services. After opening its new Willoughby Street headquarters in Brooklyn, the group's Michael Kink said, "The AIDS epidemic in New York is a combination of racial disparities, poverty and income disparities, gender disparities and immigration disparities, and that all comes together in Brooklyn."

City Councilmember Yvette Clarke said Brooklyn has "a burgeoning working-class immigrant population who don't get the type of medical attention that other populations may get." Department of Health figures show that between January and September 2003, there were 28,000 people with HIV/AIDS in Manhattan, almost 22,000 in Brooklyn, and 19,504 in the Bronx. Yet during that same period, Brooklyn had the most AIDS deaths -- 379 -- followed by the Bronx with 325 and Manhattan with 312. "Blacks and Latinos are eight out of 10 AIDS cases in the city. The epidemic in Brooklyn is overwhelmingly made up of people of color," Kink said. (New York Post, 10.07.04, Hasani Gittens)

Most Gay Men With HIV Practice Safer Sex

According to a new CDC study released Thursday, most HIV-infected gay and bisexual men in the United States are taking steps to avoid transmitting the virus. The study was conducted between May 2000 and December 2002 in 16 states; it surveyed 1,923 people, all of whom were gay or bisexual men diagnosed with HIV for longer than 12 months.

Thirty-one percent had abstained from sex with men in the previous year. Among those who were sexually active, 43 percent reported only one partner. The men were 3.5 times more likely to use a condom when having sex with an uninfected partner. However, about 14 percent of the men did not use a condom the last time they had insertive anal intercourse with an uninfected partner. Twenty-five percent did not use a condom the last time they had sex with a person of unknown HIV serostatus.

"These findings underscore the need to help HIV-positive individuals maintain safer behaviors over the long run," said the CDC report. CDC has made diagnosing and treating people with HIV the key element of its HIV prevention strategy. Men who have sex with men account for a majority of the estimated 950,000 US HIV cases. (Reuters, 09.30.04, Paul Simao)

Cost Of AIDS Therapy Out of Reach for Many

In August, the Food and Drug Administration approved Sculptra, a new treatment for the facial wasting that can be a side effect of HIV drugs. Its maker, Dermik Laboratories of Berwyn, Pa., set the US price at almost four times the price in Europe, where it has been used since 1999. Sculptra sells for $125 per bottle in Europe and South America but $480 in the United States, said Dr. Peter Engelhard, director of Apex South Beach Clinic, which specializes in treating HIV atrophy. Each treatment requires two to three bottles; each patient needs three to six treatments; and one to two bottles are needed every one to years for maintenance treatments, Engelhard said.

Karen Boyce, Dermik's manager of communications, said the company is developing a patient-access program for those who cannot afford Sculptra; details should be available in late October. She noted that Sculptra is sold not to patients but to doctors; she suggested physicians could set lower prices for patients with hardships. Engelhard said he had 170 patients on a waiting list before Sculptra was approved, but after approval and the price hike, all but 30 said they could not afford it. "They're either getting a different product or none at all. It's too bad because this is the best one," he said.

Insurance companies are unlikely to cover Sculptra because they consider it a cosmetic treatment, like Botox for wrinkles, Engelhard said. He disagrees, comparing it instead to reconstructive procedures following breast cancer surgery. "People do things like stop taking their medications because of atrophy, and that does change their longevity," he said.

Jonathan Appelbaum of Boston's Fenway Community Health said coverage by state drug assistance programs is also unlikely because Sculptra is considered a treatment or device, not a drug. (Washington Blade, 09.24.04, Phil Lapadula)

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