Abstract
HIV Infection
New WHO Guidelines on Treatment and Prevention
The World Health Organization (WHO) released new HIV treatment and prevention guidelines at the Seventh International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment, and Prevention, in Kuala Lumpur, Malaysia. The recommendations include initiating antiretroviral therapy when an infected adult's CD4 T cell count drops to 500 cells/mL or lower, a change from the ≤350 cells/mL in the 2010 guidelines. The recommendations also call for ART to be started regardless of the CD4 count in children younger than 5 years of age, pregnant and breastfeeding women, partners of uninfected individuals, and persons co-infected with hepatitis B or with active TB. The recommended treatment for adults, pregnant women, adolescents, and older children is a single, fixed-dose pill.
Source: Ramakant B. New WHO Guidelines on HIV Treatment and Prevention. Media for Freedom, July 5, 2013. Available at
How to Transition HIV-Infected Youths to Adult Care
The success of antiretroviral therapy has ensured that most HIV-infected children survive to adulthood. The American Academy of Pediatrics (AAP) has issued a policy statement with specific recommendations for developing and implementing a formal plan for the transfer of HIV-infected youth to adult health care providers. This plan should be established in early adolescence and modified as needed as the time for transition nears. Communication among providers is crucial and should comprise personal contact and written documentation, with progress toward the transfer and assessments tracked over time. Throughout the transition, the patient's health care coverage should be evaluated regularly to make sure that coverage of care and access to medication is uninterrupted. The youth's educational, vocational, and social service needs are an important part of the transition process. The AAP identifies four key steps in the transition process: the development of written policies to define the process; the creation of an individualized transition plan jointly by the provider, patient, and family that should include a portable medical summer and an emergency care plan; preceding transition to the adult HIV care provider with appropriate communication that should include a transfer letter and portable medical summary; and documentation of the completed transfer and evaluation of the outcome of the process.
Source: American Academy of Pediatrics. Policy statement: transitioning HIV-infected youth into adult health care. Pediatrics 2013;132:192–197.
Cancer Incidence Related to the Initiation of ART
Different types of cancer tend to affect HIV-infected patients at different times. A study of the incidence and timing of cancer diagnoses among patients initiating ART between 1996 and 2011 showed that AIDS-defining cancers such as Kaposi's sarcoma and non-Hodgkin's lymphoma were most likely to occur during the first 6 months after ART initiation; their incidence rates would fall during the following 6-month period and then remain low. In contrast, incidence rates for non-AIDS defining cancers such as HPV-related cancers and non-lymphoma cancers increased at each year of follow-up, likely due to aging. For all cancers evaluated, a greater risk of diagnosis was associated with a lower CD4 count at ART initiation.
Sources: Yanik EL, Napravnik S, Cole SR, et al. Incidence and timing of cancer in HIV-infected individuals following initiation of combination antiretroviral therapy. Clin Infect Dis 2013; doi:10./1093/cid/cit369.
HIV Diagnosis and Treatment Differences Among U.S. Subpopulations
A study intended to determine the percentage of persons living with HIV in the U.S. who are either aware or unaware of their HIV status–and if aware of their infection are linked to care, retained in care, receiving antiretroviral therapy, and achieving viral suppression–based its findings on 2009 data from the National HIV Surveillance System of the Centers for Disease Control and Prevention. Of the more than 1.1 million people living with HIV at that time, nearly 82% had received an HIV-positive diagnosis; 65.8% were linked to care, 36.7% were retained in care, 32.7% had been prescribed antiretroviral therapy, and 25.3% had achieved a suppressed viral load, defined as ≤200 copies/mL. Approximately three-quarters of the HIV-infected individuals in the U.S. had not achieved viral suppression, including 74.8% of males, 79.0% of blacks, 73.9% of Hispanics/Latinos, and 70.3% of whites. Among teens and young adults infected with HIV, ages 13–24 years, only 40.5% had received a diagnosis and 30.6% were linked to care.
Source: Hall HI, Frazier EL, Rhodes P, et al. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Intern Med 2013; doi:10.1001/jamainternmed.2013.6841.
Two Men Have Undetectable HIV After Bone Marrow Transplants
Drs. Timothy Henrich and Daniel Kuritzkes, Brigham and Women's Hospital (Boston, MA), reported the apparent eradication of HIV in two infected patients at the recent International AIDS Society Conference. The two men had received bone marrow transplants to treat lymphoma, and after the transplants no longer had detectable levels of HIV in their blood. This lack of detectable HIV persisted, and even for weeks after each transplant recipient stopped antiretroviral therapy. In one of the men whose rectal tissue was screened for HIV, no virus was detected in that sample either. These cases differ from the 2007 case of Timothy Brown (the “Berlin Patient” who remains HIV-free after a bone marrow transplant to treat leukemia), as he received donor cells that contained a mutation, making them resistant to the strain of HIV causing his infection.
In Journal of Infectious Diseases, Henrich, Kuritzkes, and co-authors demonstrated that following allogeneic stem cell transplantation with reduced-intensity conditioning, HIV became undetectable in peripheral blood mononuclear cells, CD4+ T cells, and blood plasma. They concluded that antiretroviral therapy was able to fully suppress HIV replication and did not contribute to the maintenance of viral reservoirs in peripheral blood, as the donor cells were able to engraft without evidence of HIV infection.
Sources: Eryn Brown. 2 Men with HIV Who Had Bone Marrow Transplants Remain Virus Free. Los Angeles Times. July 3, 2013. Available at
Henrich TJ, Hu Z, Li JZ, et al. Long-term reduction in peripheral blood HIV type 1 reservoirs following reduced-intensity conditioning allogeneic stem cell transplantation. J Infect Dis 2013;207:1694–1702.
HIV Shedding in Semen of MSM on ART
Men with well-controlled HIV infection and undetectable viral levels in their blood may still shed HIV in their semen. A study of HIV-infected men who have sex with men (MSM) who had blood plasma HIV levels <500 copies/mL on antiretroviral therapy were screened for the presence of HIV and seven human herpesviruses in semen samples using real-time polymerase chain reaction (PCR). Detectable levels of seminal HIV were found in 9.6% of subjects, and at least one herpesvirus was present in 63.2% of the seminal plasma samples. Detectable levels of seminal HIV were less likely in persons with blood plasma HIV levels <50 copies/mL compared to those with blood HIV levels 50–500 copies/mL. Another notable finding was the association between high levels of cytomegalovirus (CMV, <4 log10 DNA copies/mL) in semen with detectable seminal HIV levels.
Source: Gianella S, Smith DM, Vargas MV, et al. Shedding of HIV and human herpesviruses in the semen of effectively treated HIV-1-infected men who have sex with men. Clin Infect Dis 2013;57:441–447.
Hot Flashes Are More Severe in Perimenopausal HIV-Infected Women
Compared to non-HIV-infected women matched by age, race, and menstrual pattern, HIV-infected women report increased hot flash severity related to perimenopause and had a higher hot flash-related interference score. The study authors concluded that “Increased distress secondary to hot flashes may reduce quality of life and negatively impact important health-promoting behaviors, including adherence to antiretroviral therapy.”
Source: Looby SE, Shifren J, Corless I, et al. Increased hot flash severity and related interference in perimenopausal human immunodeficiency virus-infected women. Menopause 2013; doi:10.1097/GME.0b013e31829d4c4c.
Financial Incentives May Aid in HIV Prevention and Treatment
A study conducted in Lesotho evaluated whether conditional cash transfers and other financial incentives could successfully promote safer sexual activity among young people as a means of preventing HIV transmission. More than 3400 young men and women received lottery tickets for a negative result on a rapid test for a curable sexually transmitted infection such as syphilis or Trichomonas vaginalis. After 2 years of running this lottery scheme in several villages, HIV incidence was significantly lower among the study participants who were eligible for the lotteries, and especially among women and among the group of participants eligible for the high prize lotteries.
In Vancouver, Canada, a study conducted among 301 illicit drug and/or alcohol users, randomized to receive either counseling and HIV testing alone or plus modest cash incentives (on testing and for returning to receive the test results), found that 100% of those receiving incentives completed testing compared to 32% of those in the non-incentive group; and 83% in the incentives group returned for their test results, compared to 11% in the non-incentives group.
Sources: Hull M, Otieno C, Singer J, et al. Use of modest financial incentives to improve engagement of drug users in HIV testing and follow-up: results of a randomized controlled trial. oral abstract presented at the Seventh IAS Conference on HIV Pathogenesis, Treatment, and Prevention. Available at
Björkman-Nyqvist M, Corno L, de Walque D, Svensson J. Evaluating the impact of short term financial incentives on hiv and sti incidence among youth in lesotho: a randomized trial. oral abstract presented at the seventh ias conference on hiv pathogenesis, treatment, and prevention. Available at
HPV Infection
Vaccine Linked to Declining Infections in Young Women
The prevalence of human papillomavirus (HPV) infection caused by virus types targeted by the HPV vaccine, which was introduced as part of the routine immunization schedule for teenage and young adult women in 2006 in the U.S., is an indicator of the impact of the vaccine. Data compiled from 2003 to 2010 as part of the National Health and Nutrition Examination Surveys, indicate that among females aged 14–19 years, the vaccine-type HPV prevalence decreased from 11.5% in the prevaccine era (2003–2006) to 5.1% in the vaccine era (2007–2010). This corresponds to a significant decline of 56%. No significance difference in prevalence was noted for other age groups between the two time periods. The authors reported that, although vaccine usage was relatively low–only 32% of 13- to 17-year-olds completed the three-dose immunization in 2010–the effectiveness of at least one dose of vaccine was approximately 82%. The reduction in vaccine type prevalence was greater than expected, and the authors attribute this to several possible factors: herd immunity, high effectiveness of a less than full immunization dose, and/or changes in sexual behavior.
“This report shows that HPV vaccine works well, and the report should be a wake-up call to our nation to protect the next generation by increasing HPV vaccination rates,” said Tom Frieden, MD, MPH, Director of the U.S. Centers for Disease Control and Prevention (Atlanta, GA). “Our low vaccination rates represent 50,000 preventable tragedies–50,000 girls alive today will develop cervical cancer over their lifetime that would have been prevented if we reach 80% vaccination rates,” he added.
Two HPV vaccines are commercially available: Gardasil® from Merck, a quadrivalent vaccine that protects again HPV 6, 11, 16, and 18, and Cervarix, from GlaxoSmithKline, which protects against HPV 16 and 18. HPV vaccination was recommended for all girls beginning in 2007, and expanded to include boys in 2011. Cost will no longer be an impediment to vaccination, as new health care laws will require insurance providers to cover the cost of the vaccine.
Sources: Markowitz LE, Hariri S, Lin C, et al. Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, National Health and Nutrition Examination Surveys, 2003–2010. J Infect Dis 2013;208:385–393.
Centers for Disease Control and Prevention. Press release: New study shows HPV vaccine helping lower HPV infection rates in teen girls. June 19, 2013. Available at
Tavernise S. Vaccine is credited in steep fall of HPV infection in teenagers. New York Times June 20, 1013, p. A1.