International AIDS Society Conference Research Articles

Language matters: The importance of person‐first language and an introduction to the People First Charter

Language matters: The importance of person‐first language and an introduction to the People First Charter

Pre-exposure Prophylaxis Uptake, Adherence, and Persistence: A Narrative Review of Interventions in the U.S.

Since 2012, HIV pre-exposure prophylaxis (PrEP) has been available to prevent HIV transmission; yet, uptake, adherence, and persistence to PrEP have been suboptimal. This narrative review examines the latest interventions and programs to improve all 3 stages of PrEP adherence and reviews ongoing studies to promote effective PrEP use. From 2017 to 2020, a total of 20 studies analyzed different individual- and structural-level approaches to increase PrEP adherence, including behavior change interventions, technology-based interventions (e.g., short message service messages and mobile applications), and alternate delivery strategies (e.g., pharmacy-based PrEP, integration with other services, and home delivery). Most published interventions involved men who have sex with men, although 3 assessed women (2 transgender, 1 cisgender). Randomized, controlled data support 3 behavioral change interventions and 1 technology-based intervention. Alternate delivery strategies seem promising, although more robust study designs are generally needed. In addition, data on the alignment of ongoing HIV risk and PrEP persistence (i.e., prevention-effective adherence) were limited. The authors also identified 20 ongoing studies that are promoting PrEP adherence. Future work should be inclusive of all at-risk groups in the U.S., including African American and Latinx heterosexual populations and people who inject drugs. Proven and promising approaches may work well in combination and may also need to be adapted with the introduction of long-acting pre-exposure prophylaxis formulations. Collectively, this body of work indicates considerable progress toward understanding the role PrEP adherence will play in Ending the HIV Epidemic in the U.S. that will be bolstered by the outcomes of ongoing trials.

A pandemic anniversary: 40 years of HIV/AIDS

A pandemic anniversary: 40 years of HIV/AIDS

David Katzenstein and James Hakim-In Memoriam.

The world lost two wonderful doctors who devoted their lives to the fight against HIV/AIDS in Africa. Ironically, they both died of COVID-19 within hours of each other in late January in Zimbabwe. David Katzenstein, MD, began his career in the early 1980 s working with underserved populations at a Native Tribal clinic in New Mexico and with persons suffering from AIDS at the Haight Ashbury Clinic in San Francisco, conducted CMV research at the University of Minnesota, and then took a position working as a microbiologist at the University of Zimbabwe in Harare between 1985 and 1987. In 1989, David joined the faculty at Stanford University where he remained until his retirement in 2017. Dr Katzenstein, led many important clinical and translational research studies related to HIV. With his colleagues in the AIDS Clinical Trials Group (ACTG), he led studies that resulted in the approval of life-saving antiretroviral medications. David dedicated a major portion of his academic endeavors to study HIV drug resistance, serving as director of one of the Virology Specialty Laboratories for the ACTG for many years. He was a protocol team member and leader on several ACTG studies and served on numerous ACTG committees, including the Performance Evaluation Committee and the original Virology Committee. He was co-chair of ACTG 384 that dealt with protease and/or non-nucleoside reverse transcriptase inhibitors, and was one of the first investigators to call attention to the issues of drug resistance in Africa. Recognizing the disparate impact of HIV in resource limited settings, David was a pioneer in Global HIV Research, in the fields of perinatal HIV transmission prevention, and studying different approaches to optimize antiretroviral treatment and laboratory monitoring in various settings around the world. He worked diligently to bring laboratory technology to Zimbabwe. Following his retirement from Stanford in 2017, David became the director of the Biomedical Research Training Institute in Zimbabwe where he led the molecular diagnostics laboratory to support laboratory monitoring of community-based treatment programs. In all his work, David engaged researchers and trainees from different parts of the world. Generous with his time, effort and ideas, David was a cherished mentor for many young and mid-career physicians and scientists, now scattered throughout different academic institutions and agencies in the U.S. He nurtured careers of clinicians, basic and social scientists, while encouraging multidisciplinary efforts to tackle the global HIV pandemic. He worked tirelessly and with great joy, giving of himself without reserve. James Gita Hakim, MRCP-UK, Professor of Medicine, University of Zimbabwe College of Health Sciences, to COVID-19. Dr Hakim was an accomplished investigator who made seminal contributions in HIV treatment and prevention research. He was known internationally for his accomplishments as a research leader, a builder of African research capacity, a leader of modernizing medical education in Africa, and as a mentor of young African investigators. Dr Hakim was at the forefront of clinical research on HIV/AIDS in Africa for over 20 years. He founded the University of Zimbabwe Clinical Research Centre (UZ-CRC) in 2001 as a site for international clinical trials on HIV treatment and prevention. He was a leader in pivotal international clinical trials including the landmark HIV ‘treatment as prevention’ trial HPTN 052, the MRC-funded “Development of Anti-Retroviral Therapy in Africa” (DART) trial, and the ACTG “Prospective Evaluation of Antiretroviral Therapy in Resource Limited Settings” (PEARLS) study. These studies contributed to the knowledge needed for successful implementation of antiretroviral therapy in southern Africa. Dr Hakim was as Principal Investigator of the University of Zimbabwe's program, the Medical Education Partnership Initiative (MEPI) which serves as a model for medical education in Africa. He was as a representative on the International AIDS Society (IAS) Governing Council from 2016 to 2020 and on the World Health Organization Guidelines Review Committee, the UNAIDS Advisory Committee, and on program committees for IAS Conference on HIV Science, the Conference on Retroviruses and Opportunistic Infections (CROI). Dr Hakim was Co-chair of the World AIDS Conference, Amsterdam, Netherlands in 2018. James Hakim's life demonstrated how investment in biomedical research and modern medical education can pay large dividends and be transformative for Africa. The world is better for the lives you lived, David and James. May light perpetual shine upon you.

Nurses\u2019 perceptions on implementing a task-shifting/sharing strategy for hypertension management in patients with HIV in Nigeria: a group concept mapping study

BackgroundPeople living with HIV (PWH) in Africa have higher burden of cardiovascular diseases (CVD) compared to the general population, probably due to increased burden of hypertension (HTN). In this study, we explored nurses’ perceptions of factors that may influence the integration of an evidence-based task-shifting/sharing strategy for hypertension control (TASSH) into routine HIV care in Lagos, Nigeria.MethodsUsing group concept mapping, we examined the perceptions of 22 nurses from HIV clinics in Lagos. Participants responded to a focused prompt on the barriers and facilitators of integrating TASSH into HIV care; next, separate focus groups generated relevant statements on these factors; and statements were then sorted and rated on their importance and feasibility of adoption to create cluster maps of related themes. The statements and cluster maps were categorized according to the Consolidated Framework for Implementation Research (CFIR) domains.ResultsAll study participants were women and with 2 to 16 years’ experience in the provision of HIV care. From the GCM activities, 81 statements were generated and grouped into 12 themes. The most salient statements reflected the need for ongoing training of HIV nurses in HTN management and challenges in adapting TASSH in HIV clinics. A synthesis of the cluster themes using CFIR showed that most clusters reflected intervention characteristics and inner setting domains. The potential challenges to implementing TASSH included limited hypertension knowledge among HIV nurses and the need for on-going supervision on implementing task-shifting/sharing.ConclusionsFindings from this study illustrate a variety of opinions regarding the integration of HTN management into HIV care in Nigeria. More importantly, it provides critical, evidence-based support in response to the call to action raised by the 2018 International AIDS Society Conference regarding the need to implement more NCD-HIV integration interventions in low-and middle-income countries through strategies, which enhance human resources. This study provides insight into factors that can facilitate stakeholder engagement in utilizing study results and prioritizing next steps for TASSH integration within HIV care in Nigeria.

Current perspectives on paediatric HIV management from the Mexico International Aids Society Conference, 2019.

While acknowledging the great achievements in getting 23 million people living with HIV to access antiretroviral treatment (ART) globally, there is still more to do in order to close the HIV treatment gap between the paediatric and adult ART programmes, with only 54% of children accessing ART compared to 62% of adults. Furthermore, while tremendous global gains have been made in preventing perinatal and postnatal HIV acquisition, HIV-exposed and uninfected children are still not achieving early childhood developmental outcomes comparable to HIV-unexposed children. In this article, we present highlights from two pre-conference meetings (11th International Workshop on HIV Pediatrics and 5th Workshop on Children and Adolescents HIV Exposed and Uninfected) and the International Aids Society (IAS) meeting held in Mexico in July 2019.

Mortality among pediatric patients on HIV treatment in sub-Saharan African countries: a systematic review and meta-analysis

BackgroundDespite substantial improvements in accessibility of Anti-Retroviral Treatment (ART), death of children on ART remains a prevailing challenge in sub-Saharan African (SSA) countries. However, the pooled magnitude of mortality at different ART follow-up periods remains unknown for the region. We estimated the pooled proportion of all-cause mortality for pediatric patients receiving first-line ART at 3, 6, 12, and 24 months follow-up period in SSA.MethodsWe searched for relevant articles published between January 2014 and June 2018 on PubMed, Hinari and Google scholar databases. We searched for additional articles from reference lists and 2014–2018 abstracts archived by the Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society Conference on HIV Science (IAS).ResultsWe reviewed 29 articles reporting mortality among pediatric ART patients at different follow-up periods in countries from 2001 to 2016. Among the 51,619 pediatric ART patients in these cohorts, studies reported 4061 (7.9%) all-cause cumulative death. The cumulative pooled proportion of mortality at 3, 6, 12 and 24 months of ART were 3% (95% CI: 3.0–4.0), 5% (95% CI: 4.0–6.0), 6% (95% CI: 5.0–7.0) and 7% (95% CI: 6.0–8.0), respectively.ConclusionsIn SSA, significant proportion of mortality among children occurs in the first 3–6 months of ART initiation. Western Africa has a little higher estimate of mortality among pediatric ART patients at 6 and 12 months of follow-up. Strategies to prevent early mortality including thorough screening and management of opportunistic infections before ART initiation are needed.

HIV-1 drug resistance before initiation or re-initiation of first-line antiretroviral therapy in low-income and middle-income countries: a systematic review and meta-regression analysis

SummaryBackgroundPretreatment drug resistance in people initiating or re-initiating antiretroviral therapy (ART) containing non-nucleoside reverse transcriptase inhibitors (NNRTIs) might compromise HIV control in low-income and middle-income countries (LMICs). We aimed to assess the scale of this problem and whether it is associated with the intiation or re-initiation of ART in people who have had previous exposure to antiretroviral drugs.MethodsThis study was a systematic review and meta-regression analysis. We assessed regional prevalence of pretreatment drug resistance and risk of pretreatment drug resistance in people initiating ART who reported previous ART exposure. We systematically screened publications and unpublished datasets for pretreatment drug-resistance data in individuals in LMICs initiating or re-initiating first-line ART from LMICs. We searched for studies in PubMed and Embase and conference abstracts and presentations from the Conference on Retroviruses and Opportunistic Infections, the International AIDS Society Conference, and the International Drug Resistance Workshop for the period Jan 1, 2001, to Dec 31, 2016. To assess the prevalence of drug resistance within a specified region at any specific timepoint, we extracted study level data and pooled prevalence estimates within the region using an empty logistic regression model with a random effect at the study level. We used random effects meta-regression to relate sampling year to prevalence of pretreatment drug resistance within geographical regions.FindingsWe identified 358 datasets that contributed data to our analyses, representing 56 044 adults in 63 countries. Prevalence estimates of pretreatment NNRTI resistance in 2016 were 11·0% (7·5–15·9) in southern Africa, 10·1% (5·1–19·4) in eastern Africa, 7·2% (2·9–16·5) in western and central Africa, and 9·4% (6·6–13·2) in Latin America and the Caribbean. There were substantial increases in pretreatment NNRTI resistance per year in all regions. The yearly increases in the odds of pretreatment drug resistance were 23% (95% CI 16–29) in southern Africa, 17% (5–30) in eastern Africa, 17% (6–29) in western and central Africa, 11% (5–18) in Latin America and the Caribbean, and 11% (2–20) in Asia. Estimated increases in the absolute prevalence of pretreatment drug resistance between 2015 and 2016 ranged from 0·3% in Asia to 1·8% in southern Africa.InterpretationPretreatment drug resistance is increasing at substantial rate in LMICs, especially in sub-Saharan Africa. In 2016, the prevalence of pretreatment NNRTI resistance was near WHO's 10% threshold for changing first-line ART in southern and eastern Africa and Latin America, underscoring the need for routine national HIV drug-resistance surveillance and review of national policies for first-line ART regimen composition.FundingBill & Melinda Gates Foundation and World Health Organization.

Tenofovir Alafenamide Versus Tenofovir Disoproxil: Systematic Review and Meta-analysis (Protocol)

Highly active antiretroviral therapy (HAART) has greatly reduced morbidity and mortality, resulting in high survival rates among infected patients. Despite the impact of HAART, mortality in successfully treated HIV infected patients remains higher than in the general uninfected population. The effects of persistent inflammation and drug toxicity on comorbidities that are considered non-HIV related, including metabolic, cardiovascular and renal disease, contribute to these differences in the health of infected individuals New Reference. Among antiretroviral moleculars, tenofovir disoproxil is widely used. Tenofovir alafenamide is a new oral prodrug of tenofovir, a nucleotide analogue that inhibits HIV-1 transcription. Tenofovir alafenamide has potential intracellular accumulation; lower extracellular exposures of tenofovir may be realized with the potential to reduce off-target toxicities. Specifically, lower drug exposures to kidney cells may provide for fewer renal complications as observed in a minority of patients treated with tenofovir disoproxil fumarate. Objectives To investigate whether Tenofovir alafenamide based regimens are less nephrotoxic than Tenofovir disoproxil based regimens. To evaluate whether Tenofovir alafenamide contained regimens could decrease mineral bones loss. To investigate the efficacy of TAF in co-infection HIV/hepatitis. Search methods: We will search the following electronic databases: CENTRAL (Cochrane Central Register of Controlled Trials), Scorpus, Web of science, LILACS, PubMed and CINAHL. We will also search conference abstract archives on the web sites of the Conference on Retroviruses and Opportunistic Infections (CROI), the International AIDS Conference (IAC), and the International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS). Analysis: If include studies are as similar as possible, we will undertake meta-analysis using Cochrane’s Review Manager Software (RevMan 2014). If included studies are heterogeneous, the results will be summarized in a narrative manner. GRADE evidence profiles and summary of findings tables will be generated. Conclusion: This study could influence HIV management. TDF is largely used as first line regimen in HIV management. Therefore toxicity is restricted its use. This systematic review will find out whether TDF could be swift by TAF when TDF is contraindicated.

Mobile Phone Communication for Improving Uptake of Antiretroviral Therapy in HIV-infected Pregnant Women: Review

Background About 1.4 million pregnant women are living with HIV in low and middle income countries with about 91% of these women residing in sub-Saharan Africa. HIV-infected pregnant women face several challenges that could decrease antiretroviral therapy adherence. Studies reported challenges such as poor mental health, lack of social support, fears of infecting children, medication side effects, cultural factors, economic instability, nausea and vomiting during pregnancy. This review investigated whether mobile phone text messaging could improve antiretroviral therapy in during and after pregnancy. Objectives To assess the effectiveness mobile phone text messaging for improving adherence to antiretroviral therapy in HIV-infected pregnant women. To investigate whether mobile phone text messaging could improve follow up in HIV-exposed infants. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, MEDLINE via PubMed, Web of Science, CINAHL (EBSCO). Furthermore, we searched studies through HIV/AIDS conferences websites: International AIDS conferences, The European AIDS Clinical Society (EACS) conferences, International AIDS Society conference on HIV Pathogenesis and Treatment (IAS). Two authors extracted data in the study eligibility form. Selection criteria We selected randomized controlled trials (RCTs) assessing mobile phone text messaging as reminders for antiretroviral therapy uptake in HIV-infected pregnant women. Data collection and analysis Two authors independently identified and assessed all studies that met inclusion criteria. Study design, characteristics of study populations, interventions and controls and study results were extracted by two review authors. In addition, the risk of bias of included studies was assessed independently by two reviewers. We reported the results narratively as meta-analysis was not feasible because of differences in the study design. We reported the odds ratio with 95% confidence intervals for the different outcomes. Main results We identified five eligible studies; three ongoing and two completed studies. Findings from the included studies showed that mobile phone text messaging did not increase antiretroviral therapy initiation (OR 1.79 95%CI 1.09 to 2.94, 307 participants, 1 study). However, there was an increase in maternal clinic attendance and HIV tested infants; (RR 1.66 95%CI 1.02 to 2.70, 381 participants, 1 study) and (OR 2.01 95%CI 1.03 to 3.92, 325 participants, 1 study), respectively. The overall quality of evidence was assessed as moderate. None of the included studies reported on adherence to antiretroviral therapy. Authors' conclusions The review revealed that mobile phone text messaging may improve maternal clinic attendance and number infants tested for HIV compared to the standard care. Mobile phone communication did not improve ART initiation compared to standard care. Further studies are needed to evaluate the value of mobile phone communication in promoting adherence to antiretroviral drugs among pregnant women and reduction of mother-to-child transmission of HIV.

Physicians Focus on Primary Care for Patients With HIV

Many patients with HIV infection who receive treatment can now expect to live a near-normal life span. Rapid progress in the treatment of HIV has changed the diagnosis from a death sentence in the 1980s and early 1990s to a treatable but life-shortening illness in the 2000s. Today, HIV infection is a condition that many patients may successfully manage into their golden years, according to data presented by Robert S. Hogg, PhD, professor of health sciences at Simon Fraser University, and colleagues at the International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention (http://bit.ly/1cXihmg). Yet this triumph of modern medicine has created a new set of challenges for clinicians. Many patients with HIV are living long enough to develop chronic conditions, such as heart disease, that are common in the overall primary care population. That means that HIV specialists and primary care physicians who treat patients with HIV now have to learn to integrate their HIV patients’ primary care needs into their overall treatment. To help them do so, the HIV Medicine Association (HIVMA) has released an updated guideline on primary care for patients with HIV (Aberg JA et al. Clin Infec Dis. doi:10.1093/cid /cit665 [published online November 13, 2013]). Helping HIV specialists bring their pr imary care sk i l l s up-to-date is a key focus of the HIVMA guideline, according to Joel Gallant, MD, associate medical director of specialty services at Southwest CARE Center in Santa Fe, New Mexico, and chair of the HIVMA board of directors. “Therapy for HIV is so effective, most patients come to us with issues that are primary care issues,” explained Gallant. Some of the primary concerns facing these patients are specific to HIV; some are the same as those facing the general population. For example, patients with HIVmay be at greater risk for bone density loss as a result of their condition or treatment. So the new guideline recommends that men with HIV as well as postmenopausal women be screened for bone density loss. New Focus, Need for Training Speeding the adoption of advances in HIV care into practice has been a focus of HIV specialists and public health organizations since the epidemic emerged. This emphasishashelped translatenewdiscoveries into practicewithinmonths, rather thantheyears it typically takes forclinicaladvancestomake their way into medicine, said Laura W. Cheever, MD, ScM, associate administrator of the HIV/AIDS Bureau at the Health ResourcesandServicesAdministration.Thebureau administers the Ryan White HIV/AIDS Program,whichwas established in 1990by theUSgovernment to provide comprehensivecareforvulnerablepopulationswithHIV. Recently the community health centers have begun emphasizing a new set of treatmentchallenges, includingbettermanagement of cholesterol and smoking cessation. Cheever noted that for many specialists, these are newer considerations; when patients hadonly6months to live, she said, physicians were likely to tell patients “they can smoke as much as they want.” The general shift in focus means many HIV specialists must brush up on their

Interventions to improve adherence to antiretroviral therapy in children with HIV infection

Achieving and maintaining high levels of medication adherence are required to achieve the full benefits of antiretroviral therapy (ART), yet suboptimal adherence among children is common in both developed and developing countries. To conduct a systematic review of the literature of evaluations of interventions for improving paediatric ART adherence. We created a comprehensive search strategy in order to identify all studies relevant to this topic. In July 2010, we searched the following electronic databases: EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, LILACS, Web of Science, Web of Social Science, NLM Gateway (supplemented by a manual search of the most recent abstracts not included in the Gateway database). We searched abstracts from the International AIDS Conference from 2002 to 2010, the International AIDS Society Conference on Pathogenesis, Treatment and Prevention from 2003 to 2009, and from the Conference on Retroviruses and Opportunistic Infections from 1997 to 2010. We used search strategies determined by the Cochrane Review Group on HIV/AIDS. We also contacted researchers who work in this field and checked reference lists of related systematic reviews and of all included studies. Randomised and non-randomised controlled trials of interventions to improve adherence to ART among children and adolescents (age ≤18 years) were included. Studies had to report adherence to ART as an outcome. After one author performed an initial screening to exclude citations that did not meet the inclusion criteria, two authors did a second screening of those citations that likely met the criteria. For all articles that passed the second screening, full articles were pulled in order to make a final determination. Two authors then extracted data and graded methodological quality independently. Differences were resolved through discussion. Four studies met the inclusion criteria. No single intervention was evaluated by more than one trial. Two studies were conducted in low-income countries. Two studies were randomised controlled trials (RCT), and two were non-randomised trials. An RCT of a home-based nursing programme showed a positive effect of the intervention on knowledge and medication refills (p=.002), but no effect on CD4 count and viral load. A second RCT of caregiver medication diaries showed that the intervention group had fewer participants reporting no missed doses compared to the control group (85% vs. 92%, respectively), although this difference was not statistically significant (p=.08). The intervention had no effect on CD4 percentage or viral load. A non-randomised trial of peer support group therapy for adolescents demonstrated no change in self-reported adherence, yet the percentage of participants with suppressed viral load increased from 30% to 80% (p=.06). The second non-randomised trial found that the percentage of children achieving >80% adherence was no different between children on a lopinavir-ritonavir (LPV/r) regimen compared to children on a non-nucleoside reverse transcriptase regimen (p=.781). However, the proportion of children achieving virological suppression was significantly greater for children on the LPV/r regimen than for children on the NNRTI-containing regimen (p=.002). A home-based nursing intervention has the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence or disease outcomes. Two interventions, an LPV/r-containing regimen and peer support therapy for adolescents, did not demonstrate improvements in adherence, yet demonstrated greater viral load suppression compared to control groups, suggesting a different mechanism for improved health outcomes. Well-designed evaluations of interventions to improve paediatric adherence to ART are needed.

Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection

Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection

Offline: The following day, no one died

President Obama has become a hate figure for some AIDS activists. Médecins Sans Frontières, among others, claim that Obama is personally “denying and delaying AIDS treatment, ignoring evidence on how to defeat the pandemic”. These critics accuse Obama of breaking promises. One activist at the International AIDS Society's conference in Vienna last week said that he had “lied”. Meanwhile, some of Obama's political foes level an opposite attack. They argue that he has been too kind to factions on the political left (including AIDS activists), which (his critics claim) have held him hostage to causes that hurt his centrist credentials.

5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention: summary of key research and implications for policy and practice ‐ Introduction

19‐22 July 2009, 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009), Cape Town, South Africa

5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention: summary of key research and implications for policy and practice - basic sciences.

Basic science studies at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009) provided important new information that has implications not only for treatment, but also for better understanding the complex dynamics of HIV infection, epidemiology, and the impact of biology and genetics on vulnerability to HIV infection, disease progression and the risk of vertical transmission. There was renewed interest in strategies on how to eliminate residual viremia, bolster the immune system and potentially achieve viral eradication given recent evidence that antiretroviral therapy (ART) is effective at minimizing viral reservoirs if administered early in acute infection.

5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention: summary of key research and implications for policy and practice – Clinical sciences

Studies in several sub-Saharan African countries demonstrated that the expansion of antiretroviral therapy (ART) access is not only beneficial for people living with HIV, but also results in significant declines in tuberculosis and malaria incidence and prevalence, bolstering arguments for earlier and increased ART access and contributing to a growing understanding of co-epidemic dynamics. Several studies demonstrated that using standard triple-drug ART in resource-limited settings can reduce vertical transmission by as much as less than 1% if continued throughout breastfeeding.The Nevirapine Resistance Study (NEVEREST) results provided proof of concept that nevirapine could be used as part of a paediatric second-line regimen, despite exposure to nevirapine prophylaxis for vertical transmission, following successful suppression on a lopinavir/ritonavir-based regimen. A South African study found that high pre-treatment levels of inflammatory and coagulation markers were strong predictors of death, reflecting similar findings in high-income countries and reinforcing the shift towards viewing HIV as a chronic, inflammatory disease. An early study of a new integrase inhibitor (S/GSK1349572) indicated strong potency and limited cross-resistance with raltegravir, the only integrase inhibitor currently approved for treatment.

Breast is always best, even for HIV-positive mothers

Breastfeeding may be natural, but it is not always simple. Professor Anna Coutsoudis, of the Department of Paediatrics and Child Health at the University of the KwaZulu-Natal, Durban, says the problem begins in the first weeks of breastfeeding. Health-care providers lack the skills needed to offer support and advice, she says. So when problems arise--cracked nipples, babies won't suck and babies don't seem satisfied--the mothers get bad advice. Then when they become discouraged, they are told to stop breastfeeding altogether and to give artificial substitutes. If the mother is HIV positive, more uncertainty is added. counsellors are themselves confused about what is correct practice regarding HIV and feeding practices, says Thelma Raqa, an antenatal counsellor based in Mowbray Maternity Hospital in Cape Town. Until recently, the World Health Organization (WHO) advised HIV-positive mothers to avoid breastfeeding if they were able to afford, prepare and store formula milk safely. But research has since emerged, particularly from South Africa, that shows that a combination of exclusive breastfeeding and the use of antiretroviral treatment can significantly reduce the risk of transmitting HIV to babies through breastfeeding. On 30 November 2009, WHO released new recommendations on infant feeding by HIV-positive mothers, based on this new evidence. For the first time, WHO is recommending that HIV-positive mothers or their infants take antiretroviral drugs throughout the period of breastfeeding and until the infant is 12 months old. This means that the child can benefit from breastfeeding with very little risk of becoming infected with HIV. Prior research had shown that exclusive breastfeeding in the first six months of an infant's life was associated with a three- to fourfold decreased risk of HIV transmission compared to infants who were breastfed and also received other milks or foods. Instrumental in guiding the new recommendations were two major African studies that announced their findings in July 2009 at the fifth International AIDS Society conference in Cape Town. The WHO-led Kesho Bora study found that giving HIV-positive mothers a combination of antiretrovirals during pregnancy, delivery and breastfeeding reduced the risk of HIV transmission to infants by 42%. The Breastfeeding Antiretroviral and Nutrition study held in Malawi also showed a risk of HIV transmission reduced to just 1.8% for infants given the antiretroviral drug nevirapine daily while breastfeeding for 6 months. In spite of these findings it will be a challenge to change the ingrained culture of formula feeding in South Africa. Existing attitudes have been influenced by the country's high HIV-prevalence--18% of the adult population is HIV positive, according to 2008 estimates from the Joint United Nations Programme on HIV/AIDS. The 2003 South African Demographic Health Survey found that fewer than 12% of infants are exclusively breastfed during their first three months and this drops to 1.5% for infants aged between three and six months. [ILLUSTRATION OMITTED] Some health workers themselves are yet to be convinced of the benefits of breastfeeding, even for mothers who aren't HIV positive. There exists the general idea that it is not important, that there is no critical reason to breastfeed, especially when you can formula feed, says Linda Glynn, breastfeeding consultant at Mowbray Maternity Hospital in Cape Town. [health workers] think breastfeeding is a waste of time and an inconvenience. Yet, the risks of not breastfeeding often go unrecognized. Most children born to HIV-positive mothers and raised on formula do not die of AIDS but of under-nourishment, diarrhoea, pneumonia and other causes not related to HIV. Breastfeeding not only provides babies with the nutrients they need for optimal development but also gives babies the antibodies they need to protect them against some of these common but deadly illnesses. …

HIV Infection: Just an Infectious Disease?

In 2007, 2.5 million people have been newly infected with HIV and 2.1 million people died from AIDS, worldwide. HAART has turned AIDS into a manageable disease. However, numerous questions remain unanswered, such as the when to initiate HAART and what are the most effective doses of antiretroviral drugs. HIV reservoirs and how they could be attacked by therapeutic strategies is another issue. The 5th International AIDS Society (IAS) Conference in Cape Town, South Africa, focused on these subjects as well as on the hotly discussed funding budget. As has been indicated in the Sydney Declaration 2 years ago, 10% of the funding budget must be spent on clearly defined fields of HIV research. The following article presents highlights of the IAS Conference 2009.

Economic and quality of life outcomes of antiretroviral therapy for HIV/AIDS in developing countries: a systematic literature review

The impacts of antiretroviral therapy (ART) on quality of life, mental health, labor productivity, and economic wellbeing for people living with HIV/AIDS in developing countries are only beginning to be measured. We conducted a systematic literature review to analyze the effect of ART on these economic and quality of life indicators in developing countries and assess the state of research on these topics. We searched Ovid/Medline, PubMed, Psych Info, Web of Science, Google Scholar, and the abstract database of the International AIDS Society Conference and the Conference on Retroviruses and Opportunistic Infections. Both qualitative and quantitative studies were included, as were peer-reviewed articles, gray literature, and conference abstracts and presentations. Findings are reported from 21 publications, including 14 full-length articles, six abstracts, and one presentation (representing 16 studies). Compared to HIV-positive patients not yet on treatment, patients on ART reported significant improvements in physical, emotional and mental health, and daily function. Work performance improved and absenteeism decreased, with the most dramatic changes occurring in the first three months of treatment and then leveling off. Little research has been done on the impact of ART on household wellbeing, with modest changes in child and family wellbeing within households where adults are receiving ART reportrd so far. Most studies from developing countries have not yet assessed economic and quality of life outcomes of therapy beyond the first year; therefore, longitudinal outcomes are still unknown. Findings were limited geographically, with an emphasis on sub-Saharan Africa and adult treatment. As ART roll out extends throughout high HIV prevalence, low-resource countries and is sustained over years and decades, research on pediatric and differential gender economic and quality of life outcomes will become increasingly urgent, as will systematic evaluation of ART programs.