Abstract
HIV Infection
HIV/AIDS Trends Among Latinos
The year 2012 marked the 10-year anniversary of National Latino AIDS Awareness Day (NLAAD), which is intended to increase awareness of the disproportionate effect of HIV/AIDS on the Hispanic/Latino population in the U.S. This is a fact today, even as it was 10 years ago. NLAAD serves as an opportunity to encourage the practice of HIV prevention activities, including testing and linkage to care and treatment. In 2009, the estimated HIV incidence rate for Hispanics or Latinos was 26.4/100,000 population, compared to 9.1 for non-Hispanic whites. In 2009, an estimated 19.7% of HIV-positive Hispanics/Latinos in the U.S. did not know they were infected, compared to 14.8% of HIV-infected non-Hispanic whites. Data for 2010 recently published by the CDC revealed that the annual diagnostic rate for new HIV infections was 2.8 times higher for Hispanics/Latinos (20.4/100,000 persons) than for non-Hispanic whites (7.3). A comparison of the annual diagnostic rate within a 46-state region found that Hispanics/Latinos in the Northeast region had a more than two times higher rate (55.00/100,000 persons) than in other regions. In 2010, among all 46 states and Puerto Rico, an estimated 10,731 Hispanics/Latinos were newly diagnosed with HIV infection: 83.2% were males; 63.4% were men who had sex with men; 86.4% lived in urban areas; and 32.4% (the largest percentage) were 25–34 years of age. More than half of new diagnoses (54.4%) were in persons born outside of the 50 states and the District of Columbia, with the highest percentages among persons from Mexico (19.4%) and Puerto Rico (15.8%).
Sources: CDC. National Latino AIDS Awareness Day—October 15, 2012. MMWR 2012;61:805; CDC. Geographic differences in HIV infection among Hispanics or Latinos—46 states and Puerto Rico, 2010. MMWR 2012;61:805–810.
New HIV Infections Drop by More Than 50% Across 25 Countries
A new report by the Joint United Nations Programme on HIV/AIDS (UNAIDS) shows that in 25 low- and middle-income countries—more than half of them in Africa—there has been a more than 50% reduction in the rate of new HIV infections. This includes some dramatic decreases in new HIV rates in countries that have the highest HIV prevalence rates globally, such as Malawi, with a 73% drop since 2001, Botswana, with a 71% decrease, Zambia, 58%, Zimbabwe, 50%, and South Africa and Swaziland, each 41%. Substantial progress was reported in reducing new HIV infections in children, with half of the reductions in new HIV infections worldwide over the past 2 years seen among newborns. Michel Sidibé, Executive Director of UNAIDS, is quoted as saying, “It is becoming evident that achieving zero new HIV infections in children is possible.”
The report also indicates that AIDS-related deaths declined by more than 25% between 2005 and 2011 worldwide. The AIDS-related death rate has decreased by one third in sub-Saharan Africa in the last 6 years. Furthermore, great strides have been made in expanding access to antiretroviral therapy, with an increase of 63% globally during the past 24 months, and the number of people on antiretroviral treatment in sub-Saharan Africa in particular rising by 59% during that period. In China, the number of people on HIV treatment rose by nearly 50% in just the past year. The report notes a trend toward increased sharing of responsibility for the cost of HIV/AIDS care and treatment. Domestic investments among more than 81 countries increased by 50% between 2001–2011. Another positive finding was the reduction in tuberculosis-related AIDS deaths in people living with HIV, which decreased 13% in the past 24 months, associated with a 45% increase in the number of people with HIV/tuberculosis co-infection receiving antiretroviral treatment.
The UNAIDS report comes with only about 1000 days to achieve global HIV/AIDS targets identified in the Millennium Development Goals and the 2015 goals of the UN Political Declaration on HIV/AIDS. According to 2011 estimates, about 34 million people globally are living with HIV and about half do not know their HIV status. Approximately 2.5 million became newly infected with HIV in 2011 and 1.7 million people die from AIDS-related illnesses. An estimated 6.8 million people are currently eligible for treatment but do not have access. An additional 4 million discordant couples, in which one partner is HIV-infected, would benefit from treatment to protect transmission of HIV to the uninfected partner.
Source: UNAIDS Geneva Press Release. UNAIDS reports a more than 50% drop in new HIV infections across 25 countries as countries approach the 1000 day deadline to achieve global AIDS targets. Available at:
Barriers to HIV Screening Identified
Two poster presentations at IDWeek 2012, a joint meeting of the Infectious Disease Society of America, the Society for Health and Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society, shed light on why HIV screening is not routinely performed at two urban hospitals and suggest changes in practice patterns to simplify and encourage patient screening.
Marelle Yehuda and colleagues at Lenox Hill Hospital in New York City reviewed the medical records of a group of patients admitted to the department of medicine for the presence or absence of a rapid HIV antibody test or evidence that HIV screening was offered. Beginning in 2010, New York State public health law required that HIV testing be offered to all patients 13–64 years of age in emergency departments and primary care and inpatient settings. Among the patients not excluded from the study on the basis of defined criteria, 9.1% were offered screening or were screened for HIV. A random survey of residents to assess their knowledge of and attitudes toward HIV screening found that 81% were aware of the HIV testing requirement; 43% mistakenly believed that written consent was needed for rapid HIV testing. Other survey findings of note included the following: 38% of residents did not know how to order a rapid HIV screening test; 32% felt they were too busy and did not remember to do so; 24% felt HIV screening was not clinically relevant; and 22% felt their patients were not at risk. More than three-quarters (78%) of the residents expressed that adding an HIV screening option to the electronic medical record (EMR) would make them more likely to order an HIV test. The hospital instituted three changes: additional resident education regarding rapid HIV screening; HIV screening reminders were added to the EMR; and the process for ordering a rapid HIV test was simplified.
Sara Bares and co-authors distributed a questionnaire to residents in the departments of Internal Medicine, Pediatrics, Obstetrics and Gynecology, and Emergency Medicine at the University of Chicago Medical Center intended to measure their knowledge of HIV epidemiology and screening guidelines and their attitudes toward testing and testing practices. In 2001 the medical center enacted a policy of verbal-only consent for HIV testing and electronic alerts for HIV screening. The response rate was 63%, and although just over half of respondents were aware of recommendations for routine HIV screening, few followed those recommendations. Reports of routine testing in the outpatient, inpatient, and emergency room settings were 31.8%, 23.9%, and 15.9%, respectively. Some of the respondents reported not sending patients with HIV risk factors for testing. The two most common barriers to testing identified by the respondents were “competing priorities” (65.8%) and “forgetting to order the test during a patient encounter” (55.9%), and elimination of the written consent form (71.1%) and use of electronic reminders (54.1%) would be most likely to help increase routine testing.
Sources: Yehuda M, Graham R, and Ahmadi L. A missed opportunity: Identifying barriers to inpatient HIV screening. October 19, 2012, Abstract 1042; Bares S, Losavio J, Bence L, et al. Knowledge, attitudes, and ordering patterns for routine HIV screening among resident physicians at an urban medical center. October 19, 2012. Abstract 1039.
Combined Use of Hormonal Contraceptives and Condoms
While healthcare providers at family planning clinics tend to focus on helping women seeking contraception with hormonal methods such as pills, patches, cervical rings, and implants, they may be missing the opportunity at the same time to encourage continued condom use by partners and an ongoing active role by partners in contraception and family planning. A prospective cohort study among women aged 15–24 years attending a public family planning clinic and initiating hormonal contraception included a questionnaire to assess condom use and predictors of dual method contraception over a 12-month period. Among the nearly 1200 women who responded, 36% were condom users at baseline and 5% were dual method users. Condom use decreased to 27% after initiation of a hormonal contraceptive method and remained at about that level throughout the study. Dual method use increased to a high of 20% at 3 months and then gradually decreased. The authors reported that women who were condom users at baseline were nearly two times more likely than non-condom users to be dual method users at 12 months.
Source: Goldstein RL, Upadhyay UD, and Raine TR. With pills, patches, rings, and shots: Who still uses a condom? A longitudinal cohort study. J Adol Health 2012; doi:10.1016/j.jadohealth.2012.08.001
Effect of Opiate Substitution Therapy on HIV Infection Risk
A review and meta-analysis of prospective studies was conducted that directly assessed the effect of opiate substitution treatment comprising methadone maintenance therapy on HIV transmission among intravenous drug users. Worldwide about 5–10% of HIV infections are acquired due to injection drug use. It has been estimated that more than 40% of people who inject drugs may be HIV-infected in some regions of the world, and globally 3 million (range 0.8–6.6 million) of the estimated 16 million (range 11–21 million) people who inject drugs may be HIV-positive. Data from 12 published and three unpublished observational studies showed that opiate substitution treatment was associated with a statistically significant 54% reduction in risk of HIV infection among intravenous drug users.
Source: MacArthur GJ, Minozzi S, Martin N, et al. Opiate substitution treatment and HIV transmission in people who inject drugs: Systematic review and meta-analysis. Br Med J 2012;345:e5945.
Virologic Failure Halts Study of Switch to Antiretroviral Monotherapy
Simplifying antiretroviral regimens aimed at treating HIV infection could improve compliance and thereby the efficacy of treatment; however, the simplified regimen needs to be as effective as proven therapeutic protocols and be able to achieve and maintain a virologically suppressed state. In this prospective study, Katner et al. switched virologically suppressed HIV-infected patients who were receiving triple highly active antiretroviral therapy (HAART) that included lopinavir/ritonavir (LPV/r) dosed either once or twice a day to once-a-day LPV/r monotherapy for 48 weeks, with frequent clinical, virologic, and immunologic monitoring. The objective was to assess the durability of HIV virologic suppression on switching to a simplified drug regimen. The 10 patients who participated in the study maintained HIV viral loads of less than 75 copies/mL for at least 48 weeks prior to enrollment. One patient completed the 48 weeks of treatment with LPV/r monotherapy, one patient withdrew from the study early, and virologic failure occurred in four patients (due to non-adherence in two cases), at which point the study was stopped. The mean duration of virologic suppression for the five remaining patients was 36 weeks when the study was terminated.
Source: Katner H, Kumar R, Nylund C, et al. Lopinavir/ritonavir once daily monotherapy pilot study: The MONDAKAL study. Poster Abstract 1353. Presented at ID Week 2012, October 20, 2012.
HCV Infection
Interferon-Free Hepatitis C Regimen Achieves Sustained Viral Response
Abbott announced that initial results from its Aviator Phase 2b study showed that an oral triple antiviral regimen plus ribavirin–and not including interferon–for the treatment of hepatitis C genotype 1 led to sustained virological response at 12 weeks post-treatment (SVR12) in 99% of treatment-naive patients and 93% of null responders. The patients received a combination of the experimental drugs ABT-450/r, ABT-267, and ABT-333.
Source: Abbott Press Release. Abbott's investigational interferon-free hepatitis C treatment regimen achieved SVR12 (observed data) rates in 99 percent of treatment-naive and 93 percent in prior null responders for genotype 1 patients in phase 2B study. October 15, 2012. Available at: