APATHY

"AIDS Fighters Face a Resistant Form of Apathy"

New York Times (04.03.05)::Andrew Jacobs
The disappearance of condoms and HIV prevention literature from gay
bars is a telling sign of how much momentum has been lost in the US fight
against AIDS. Public health officials and AIDS advocates say many gay men
have adopted a laissez-faire attitude about safe sex, and they cite as
examples the continued popularity of crystal methamphetamine, a rise in
barebacking, and widespread apathy in which HIV is seen more as a nuisance
than a life-threatening disease. The reality that gay men continue to have
unprotected sex has vexed health experts for 20 years, though the struggle
became more pronounced with the introduction of HAART in the mid-1990s,
which sharply reduced AIDS death rates but fed the misconception that HIV is
an easily managed disease.
"Just because folks are well informed doesn't mean they'll necessarily
make the wisest choices in terms of their health," said Dr. Ronald
Valdiserri, director of AIDS prevention at CDC. "This is true of all
humanity, not just gay men."
The only hope for changing behavior, say public health experts and
psychologists, is to recognize and address the underlying factors that cause
men to take risks, such as loneliness, self-hatred, and alienation.
Perry Halkitis, a New York University psychologist who studies the
relationship between drugs and sex, said many gay men who take risks are
grappling with profound mental health issues. "They do it because the sexual
risk fulfills a need, or somehow makes them feel better about themselves,"
said Halkitis.
Other advocates say that approach is naïve and call for more personal
responsibility. Crystal meth needs to be demonized, unprotected sex must be
stigmatized, and people need to be reminded that living with HIV can be
grueling, they argue. A key first step, they say, would be for
pharmaceutical firms to stop running ads that portray life with AIDS as
carefree.

Congrats MI-POZ

MI-POZ receives $10,000 grant from Ben & Jerry's Foundation

FERNDALE - The Ben & Jerry's Foundation, the charitable organization established by the ice cream manufacturer, has made a $10,000 grant to the Michigan Positive Action Coalition to support its efforts to build effective grassroots leadership among people living with HIV and AIDS. The one-year grant will fund legislative education training sessions for people affected by HIV and AIDS in addition to legislative education activities in Washington, D.C. and a bi-monthly newsletter to inform the community about public policy issues that impact HIV care and prevention. "We're really excited about this grant," said Mark Peterson, director of MI-POZ. "The Ben & Jerry's Foundation has a long history of supporting projects that are working for systemic social change across the United States. We felt this was a perfect match." Currently operating under the umbrella of the Midwest AIDS Prevention Project, MI-POZ is the only project of its kind in Michigan that teaches people living with HIV/AIDS how to advocate for themselves and educate their elected representatives. MI-POZ received its first financial support in March 2004, a grant from the Michigan AIDS Fund. With the MAF grant, MI-POZ trained 15 people and organized meetings with state senators in Lansing to discuss pending legislation on HIV issues. MI-POZ expects to hold its next training seminar in June, and is making a special effort to recruit participants from HIV-affected African-American communities in the Detroit metro area. The training seminars are led by MI-POZ Legislative Director Rick Otterbein, who has been actively involved in legislative education activities for nearly a decade. The training workshop provides participants with basic information about state and federally-funded HIV care and prevention programs and the advocate's role in that process, including information about how government works, methods for individuals to affect change within their communities, specific strategies to impact policy decisions, and communication techniques. The training has proven successful in preparing its participants to discuss HIV issues with their elected officials, said Otterbein. "HIV-affected persons are more likely to participate in public policy development when they feel they have some degree of power over the outcome, and advocacy training workshops are effective in instilling these feelings of empowerment," said Otterbein. Anyone interested in attending a free MI-POZ training is encouraged to call Mark Peterson at 248-545-1435.

2005 PWA Guide

PWH/A Pocket Reference Guide for Spring 2005

The Spring 2005 issue of the PWH/A Pocket Reference Guide is in the final editing process. I ask that each of you look at your entry for any changes needed, please E-mail those changes to info@friendsalliance.org. Our projected timeline is to have the editing process completed VERY SOON, so that printing and distribution will occur in April. So far, I have heard from only 17 agencies on changes to be made so far. Has your agency moved in the past year? Telephone numbers changed? Services added or discontinued? Added a website or E-mail? Please send your changes now, we are going to press in just a few weeks! If you do not have a Guide handy, E-mail me or leave a message at (248)544-3320 and we will rush a copy out to you!

New POPE

Seeking a new Catholic lead on condoms
By Justin Pearce BBC News website, Johannesburg

Campaigners against Aids in South Africa are hoping that the election of a new Pope could lead to a liberalisation of the Vatican's stance on the use of condoms to prevent HIV transmission.
During his lifetime, Pope John Paul II drew criticism for refusing to moderate the Catholic Church's anti-condom stance in the face of the Aids epidemic. But some Catholics say that the Church does not ban condoms outright, and is concerned with sexual morality as well as preventing HIV transmission.

An estimated 5.3 million out of South Africa's 45 million people are living with HIV - only India has more people infected with the virus. South Africa's largest non-governmental Aids prevention programme is run by the Southern African Catholic Bishops' Conference (SACBC).
"One cannot talk about human rights without promoting reproductive rights - it's a package," Said Luyanda Ngonyama, a Catholic who previously worked for the SACBC HIV-Aids programme, and who now co-ordinates the Treatment Action Campaign (TAC) in Gauteng province.

"The Pope's teaching was limited. One understands the constraints on him, but he was the one person who had the opportunity to make a change. He lacked the will to make that change."
'Misunderstood'

Mr Ngonyama argues that the church's approach makes it difficult to take an "integrated approach" to preventing the spread of HIV.

"If one is talking about an integrated approach, one must talk about condoms: One can say that those who want to abstain can do so, but that those who wish to use condoms because of their lifestyle must be allowed to do so."

But one SACBC Aids programme staff member - who preferred to remain anonymous - said Catholic teaching on condom use was often misunderstood. The church does, for example, condone the use of condoms between a married couple where one partner is HIV-positive.
"The teaching is not against the use of condoms, but against the casualisation of sex," the SACBC worker said.

Although the arrival of a new pope was unlikely to bring about a major change, "there may be some slight shift in the recognition that some people are not able to live in monogamous relationships - some bishops already recognise that.

"The late Pope has been criticised for not coming out more clearly on the recognition that conscience plays a role [in deciding whether to use condoms] - the church's teaching is that informed conscience must be the basis for a decision."

Although the SACBC HIV programme does not distribute condoms, it does provide education and counselling on HIV prevention. "A responsible way of doing counselling is to give people all the facts they need to know how to protect themselves," the SACBC staff member said.
TAC's national spokesman Nathan Geffen said he hoped that whoever is elected to succeed John Paul "would be more liberal on social issues, and would consider changing the Catholic Church's position on reproductive choice and on the use of condoms".

Story from BBC NEWS:http://news.bbc.co.uk/go/pr/fr/-/2/hi/africa/4417521.stm

Coke & HIV

HIV-positive cocaine users have higher rates of coronary calcification



Michael Carter, Wednesday, March 30, 2005

Infection with HIV and concurrent cocaine use may contribute to the early stages of the hardening of the heart’s arteries, according to a study conducted in the US and published in the March 28th edition of the Archives of Internal Medicine. The investigators from Baltimore found that being HIV-positive, use of cocaine, and being HIV-positive and using cocaine were significantly associated with subclinical coronary calcification. Cocaine has been shown to cause arterial damage and it has been postulated that infection with HIV can contribute to cardiovascular disease through inflammatory responses to the virus. Investigators from Baltimore wished to examine the association of HIV infection, cocaine use, and a combination of HIV infection and cocaine use with coronary calcification, a marker of subclinical atherosclerosis. A total of 224 black individuals aged between 25 and 45 were recruited to the study between Spring 2000 and Spring 2003. Both HIV-positive and HIV-negative individuals were recruited to the study. Individuals were excluded if they had a diagnosis of heart disease, symptoms suggestive of heart disease, or were pregnant. Sociodemographic details and drug use information were obtained using a questionnaire. Fasting blood lipids and blood pressure were also measured and individuals underwent a computed tomographic (CT) scan to determine coronary calcium. Cocaine was used by 153 individuals (68%) and a total of 124 individuals (55%) were HIV-positive. Mean age was 38 years, however HIV-positive cocaine users were significantly younger (mean 27 years p < 0 .001). HIV-positive cocaine users were also significantly more likely to smoke, and had a significantly lower body mass index A total of 192 individuals underwent a CT scan and were included in the investigators’ analysis. The proportion of HIV-positive patients who used cocaine with coronary calcification was significantly higher than that in HIV-negative individuals with no cocaine use. The highest rate of coronary calcification was seen in HIV-positive cocaine users (38%), followed by HIV-negative cocaine users (30%), HIV-negative individuals who did not use cocaine (29%), and HIV-positive non-cocaine users (18%). However, in further analysis, the investigators also noted that amongst non-users of cocaine, HIV-positive individuals had more calcified lesions, a larger calcified area (p < 0.01), a higher calcification total volume score (p < 0.01), and a higher calcification score (p < 0.01) than HIV-negative individuals. What’s more, calcification scores were similar for HIV-positive individuals, regardless of cocaine use (p < 0.05). In multiple regression analysis, the investigators established that individuals who were HIV-positive (p = 0.05), individuals who were HIV-positive and used cocaine (p = 0.003), and HIV-negative cocaine users (p = 0.02) had higher total calcification scores. Because 75% of HIV-positive individuals were taking a protease inhibitor, a class of antiretrovirals which has been associated with accelerated atherosclerosis, the investigators conducted further analysis. This compared HIV-negative non-users of cocaine with HIV-positive non-users of cocaine who were not taking a protease inhibitor. When body mass index was accounted for, the investigators still found that being HIV-positive was significantly associated with coronary calcification (p = 0.02). “This study in young adults demonstrates a positive association of HIV infection, cocaine use, and both with coronary artery calcification. These findings suggest that HIV infection and cocaine use may be involved in the development of subclinical atherosclerosis”, write the investigators. The investigators do, however, caution that their study had a cross-sectional design “and the results from this study need to be explained with caution.” Nevetheless they conclude, “this study suggests that HIV infection, cocaine use, or both may contribute to early subclinical atherosclerotic cardiovascular disease. Studies with a larger sample size are needed to test the interaction between HIV infection and cocaine use, and clinical trials are needed to examine whether reduction in cocaine use is an effective means of preventing atherosclerosis and, thus, ameliorating the burden of coronary disease.” Reference Lai S et al. Human immunodeficiency virus 1 infection, cocaine, and coronary calcification. Arch Intern Med 165: 690 – 695, 2005.

From Test Positive Aware NetworkNovember/December 2004

The Buzz

Giraffes and HIV

Treatment Interruptions With a Twist
By Andrew Zalski, M.D.

With the recent New Year came the usual resolutions, including improving one's fitness. We're all familiar with the new crowds at the health clubs that time of year that include many people who are obviously less fit.

Wouldn't it be great if we were able to make HIV less fit, less likely to be able to replicate itself efficiently? Would having a less fit HIV virus be advantageous in managing HIV disease? Can viral fitness be measured and selected for? These are all very interesting questions, and as usual with HIV care, not all the answers to these questions are clear.
First of all, we should define some terms.

The wild type virus is essentially HIV without any significant mutations.
Mutations are changes in the viral genome. They occur as the virus replicates. Some of these mutations lead to "resistance" to HIV medications.

The viral genome is the genetic code that determines the type of virus that is produced.
Selective pressure refers to an outside force, such as an HIV medication, which pressures the virus to select for specific and characteristic mutations. With these mutations, the virus can resist or elude the effect of antiviral medicines, thus ensuring its own (viral) survival.
The classic example from evolutionary theory is the giraffe. Giraffes with longer necks were more likely to survive because they were able to eat the fruits higher up on trees, while the giraffes with shorter necks could only eat low-lying fruit. Eventually, only the giraffes with long necks would survive, although the number of giraffes would at least initially be less.
So do giraffes have anything to do with HIV management? Hardly, because if we continued the analogy, it would be better (for the fruit on the trees) to completely wipe out the population than to select for long-necked giraffes. However, these giraffes, because of their size, are not as efficient in reproducing, and thus are fewer in number. The end result is that there are fewer giraffes and more fruit. Similarly, in HIV, there might be less fit virus and more T-cells, at least for a period of time.

Replication capacity of the HIV virus can now be measured by genotypic and phenotypic testing. Replication capacity is thought to be a measure of viral fitness. A lower viral fitness may mean that the virus is weaker and less likely to replicate (make copies of itself) efficiently and less likely to cause immune system and T-cell deterioration. This would be the equivalent of selecting for the short-necked giraffe that has decreased survival capacity.
How does all this impact HIV care? The gold standard of care has been undetectable viral load and increased T-cells. There are many people with HIV who have been able to maintain undetectable (or nearly undetectable) viral load for many years.
However, some become tired of taking medications (pill fatigue), or wish to take a holiday from having to take medications, or may have developed significant side effects from the medications whereby it has direct effect on their quality of life. Some of these factors may make it medically advisable to take a treatment interruption.

Finally, on occasion where individuals have developed multiple resistance mutations, a treatment holiday is advised to encourage wild type virus to re-emerge; thus re-establishing susceptibility to antiviral medications. Would it be better for these patients to take a break from their triple medication regimen and only continue on a single (one) HIV medication which would primarily promote the selection to a less fit virus?
There is an intriguing study of patients from Italy that suggests just that. In a study designed by Antenella Castagna, M.D., patients whose virus had a M184V mutation (selected for by 3TC or FTC -- brand names Epivir or Emtriva) were randomized to two groups. The first group stopped all their HIV medications while the second group was continued on only 3TC (Epivir). After 24 weeks, the group that continued 3TC had lower viral loads and higher T-cells than the group that had stopped all HIV medications. The 3TC group continued to select (remember selective pressure) for virus that had the M184V mutation that rendered the virus "less fit."
It is important to note two facts. First, 3TC causes only a M184V mutation and no other significant mutations. Continuing an HIV medication, which selected for more than one mutation, would lead to resistance to other HIV drugs. Second, all the participants in the study already had a virus that had the M184V mutation. We would not want to select for the M184V mutation in patients whose virus does not already contain this mutation because the presence of this mutation might make the virus less susceptible to other HIV medications in the future.
Only time and further studies will let us know whether this is a useful strategy. We only have very preliminary, 24-week results which are encouraging. Further, we do not know what long-term effects may occur nor guarantee a long-term response. This may represent a reasonable strategy for those who would need, or have been medically advised to take a break from treatment and whose virus already contains the M184V mutation.

It goes without saying that this should not be attempted without discussion with your HIV care provider. In the meantime, continue to be true to your resolutions to become more fit, hope for a less fit virus, and be aware that giraffes and HIV are still quite prevalent.
Andrew Zalski, M.D., practices as an HIV specialist at Northstar Healthcare in Chicago. He is an Assistant Professor of Family Medicine at Rush University Medical Center.