Researchers Explore Prevention for Positives at the XII International AIDS Conference in Durban, South Africa
"For HIV-negative populations, strategies must be adapted to the unique needs of each group affected. And for HIV-positive individuals, for whom safer behavior has become a lifetime proposition, prevention services must be expanded and sustained."
Until recently, prevention issues have focused on people who are not infected with HIV. Following the International Conference on AIDS in Durban, however, it is clear that prevention issues are increasingly relevant and critical for people with HIV/AIDS.
In order to effectively decrease the spread of HIV, taking a multifaceted approach to prevention is critical.
Health is the Goal
The goal of prevention for people with HIV/AIDS is not only to prevent the spread of HIV, but to prevent further individual disease progression and optimize health and quality of life.
Important prevention issues for people with HIV/AIDS, which surfaced at the conference included the role of pets, preventative vaccines (e.g., influenza, hepatitis B), HIV and hepatitis coinfections, tuberculosis, and mother-to-child transmission on the health outcomes of people with HIV/AIDS.
According to a presentation at the conference, pets can be a major source of emotional support for many people with HIV/AIDS. Although zoonotic infections pose a minor threat, the actual risk of a pet owner with HIV/AIDS acquiring an infection from a pet or animal is rare overall. In most cases, good hygiene, an avoidance of young pets, and common sense can prevent the risk of illness or infection. (Session TuOr51)
A great deal of controversy surrounds the issue of vaccination. One study found that although flu immunization of patients with HIV resulted in the development of antibody titers in fewer than 50 percent of those studied, vaccination appears to be protective. Immunization did not result in predictable adverse changes in viral load or CD4 counts and progression of AIDS in HIV-asymptomatic patients was not observed (Abstract MoPeB2163).
Another study found that antibody response to pneumococcal revaccination is satisfactory for most serotypes, even in children with severe immunodeficiency (ThPeB5135). Another research group found that while vaccination may be useful, adherence by practitioners to vaccination guidelines is poor (ThPeB5069).
As people with HIV live longer, the consequences of hepatitis coinfection are increasingly contributing to morbidity and mortality. One study in Italy found one-third of in-hospital deaths in the last two years among HIV-infected individuals to be related to end-stage liver disease, mostly due to hepatitis B or C (HBV/HCV) coinfection (TuPeB3184).
Another study found that coinfection with HIV and hepatitis C increased the risk of death by approximately 50 percent over a two-and-one-half-year period (ThOrB655). In addition, HIV progression may be accelerated by the presence of HCV coinfection. Another study also found an increased risk of HIV progression with HCV infection (MoPeB2139).
Since many antiretroviral agents may be metabolized in the liver, the pharmacokinetics and tolerability of these agents may be altered by HCV coinfection. Furthermore, hepatitis may be a risk factor for NRTI-related lactic acidosis, a drug toxicity that is commonly accompanied by liver function abnormalities.
In TB news, researchers found that complex antiretroviral therapy and rifabutin (a drug used to treat TB), used to treat people with TB and HIV, may adversely affect the treatment of both diseases. Patients taking complex antiretroviral therapy were more likely to have low levels of rifabutin in the bloodstream compared to those patients who were not on antiretroviral therapy. These findings display the complexity of providing optimal care for people with HIV/AIDS at risk of TB. (TuOrB8277)
While South Africa and other developing countries are only beginning to contemplate the implementation of programs for the prevention of mother-to-child HIV transmission, developed nations, such as the U.S., are focusing their efforts on achieving complete eradication of pediatric HIV.
With HIV transmission rates reduced to less than 3 percent in most cohorts in the U.S., elective Cesarean deliveries are no longer recommended for treated women with a viral load less than 3,000 copies/ml at the time of delivery. In South Africa, no firm commitments have been made to the widespread implementation of mother-to-child HIV transmission programs.
According to the Youth Risk Behavior Surveillance System, fewer high school students are engaging in behaviors that place them at risk for HIV infection.
These decreases in sexual experience represent the first sustained reversal of the increasing trends in sexual intercourse among adolescents that occurred during the 1970s and 1980s and reflect broad efforts of families, schools, community-based organizations, and governments to reduce the impact of the AIDS epidemic in the U.S. (MoPeC2442)
In the 25 states in which HIV trends can be examined, the number of women diagnosed with HIV overall decreased by 9 percent from 1994 to 1998, although the number of young women (those born between 1975 and 1979) diagnosed with HIV more than doubled during that period (MoPeC2446).
The first comprehensive analysis of HIV incidence studies since 1978 suggests gay men and injection drug users (IDUs) continue to face dangerously high rates of infection. Infection rates among gay men in several cities dropped significantly after the intense prevention efforts in 1980s. Yet over the last decade, studies suggest that infection rates among gay men have remained roughly stable.
Among IDUs, incidence appears to have peaked in the early 1990s and has since dropped dramatically. While prevention programs have helped to increase the number of IDUs using clean needles, approximately 20 percent continue to share needles. (Source: CDC, July 8)
A study examining the relationship between gay men's optimism about HIV treatment and sexual risk behavior showed that the relationship varied among the different cities surveyed (LpPpB105).
HIV-positive men in Vancouver were significantly more optimistic than HIV-negative men, although this was not associated with high-risk behavior. Optimism was associated with high-risk behavior among HIV-negative men in London and among all men surveyed in Australia regardless of their HIV status.
This study highlights the diversity of gay men's responses in different countries to new HIV treatments, and underscores the need to continue to deliver appropriate safer sex messages to all gay men regardless of their HIV infection status.
Another study, conducted by the federal Centers for Disease Control and Prevention, also showed that optimistic attitudes about antiretroviral therapy may be contributing to increased risk behavior among young gay men (ThPeD6320).
The study found that men whose anxieties and concerns about HIV infection were reduced because of the availability of antiretroviral drugs. Those who also perceived that sex partners with low viral loads present less risk of HIV infection than those with high viral loads had more sex partners than men who did not.
According to the CDC, high-risk sexual behavior is increasing among HIV-infected men who have sex with men (MSM) in the U.S.
A CDC study found an increase in gonorrhea among HIV-infected gay men in nine cities. Considering that there is a decreasing trend in gonorrhea incidence among the general population in the U.S., the increasing trend in gonorrhea infection among HIV-infected persons is disturbing (WePeC4397).
A separate CDC study indicated that an increasing number of HIV-positive gay men are engaging in unprotected anal sex. A strong association was also found between unprotected anal sex and multiple sex partners (ThOrC714). These findings underscore a need to direct prevention research toward identifying those factors responsible for the recent increase in high-risk sexual behavior among HIV-infected MSM and to expand prevention efforts among these men.
Researchers found that men who have exclusively oral sex were split evenly between those who do not believe it poses a risk of infection and those who, despite increasing evidence of low risk, are willing to "take the chance." Men willing to take the chance are more likely to seek HIV testing (ThPeD5596).
A San Francisco study of people utilizing HIV counseling and testing sites found that people who test most frequently are at highest risk of seroconversion. They found that frequent testers are also those who practice the highest risk behavior and have the highest incidence of HIV. Contrary to previous reports, findings indicate that repeat testers are not simply the "worried well," but are indeed at high risk of seroconversion. These findings have important implications for prevention at HIV counseling and testing sites (ThPeC5424).
Nancy Wongvipat, M.P.H., manages AIDS Project Los Angeles' Prevention Program. She can be reached at firstname.lastname@example.org.
This article has been reprinted at The Body with the permission of AIDS Project Los Angeles (APLA).
This article was provided by AIDS Project Los Angeles. It is a part of the publication Positive Living.