Miami Living Magazine features the best Miami has to offer. Click on any magazine below and enjoy. You can download our free app on iTunes. Ideal for iPad and iPhone users.
Issue link: https://digital.miamilivingmagazine.com/i/182118
ML40 65-80 - ALT_Layout 1 9/26/13 8:54 PM Page 80 HEALTH HIV Report with Specialist Filippo von Schloesser Latest findings, hepatitis C & drug policies Words by Filippo von Schloesser Among the latest news on HIV infection, a particular mention of the 7th International AIDS Society Conference on HIV in Kuala Lumpur, Malaysia (June 30-July 3) must be made. The conference focused on issues relating to care and treatment of people –similar to when IAS went to Bangkok in 2004. More social issues than the implementation of the science-based evidence is now the key point. And consequently, the global attention on this region is likely to have contributed to social changes that allowed expansion of evidence based needle-exchange programs and the reduction in the use of the death penalty for drug offenses. Conference Highlights WHO Guidelines & Global Access The new and consolidated WHO guidelines were launched. In the previous WHO satellite meeting, a focus on current access highlighted that close to 10 million people in low- and middle-income countries are now taking HIV treatment. The WHO guidelines are likely to generate some of the most controversial discussions due to the shift to recommend a higher CD4 threshold for starting HIV treatment. The increase, from 350 to 500, will be based on the hopeful merger of clinical and prevention benefits. The recommendation to treat below 500 is supported by a grading of a "strong recommendation," and by a "moderate" level of evidence. How the panel arrived at this decision is less clear, as the panel only had two random clinical trials (SMART and HPTN052) to base their decision off. These were sub-analysis rather than primary endpoints, and neither study was designed to look at when to start treatment. The guidelines are based on supportive results from cohort studies and the evidence the impact treatment has on reducing transmission. These are political guidelines and it would be helpful if this was stated clearly. Where economical and social resources limit access, people with CD4 counts <350 should be prioritized for treatment. Triple therapy is recommended during pregnancy for all HIV positive women and for all children less than 5-years-old, irrespective of CD4 count. This is a bold and political move by the WHO that establishes the importance of guidelines as aspirational goals, and that the global urgency for broader access to treatment warrants this new profile above the practical difficulties and limitations of operational problems. The guidelines also suggest a strong US influence. US guidelines were the first to swing back to 500 and now recommend treatment irrespective of CD4 count. Whether what is proposed for the US will work in very different settings, with different access to drugs and different medical infrastructures will be the long-term test. Most people in the US start treatment far later than 500. 80 MIAMI LIVING Other aspects of the guidelines include: • Consolidating several guidelines into one document: adult, pediatric, pregnancy and operational guidelines are now in a single document. • That triple therapy should be the standard of care for HIV positive women who are pregnant, irrespective of CD4 count (strong recommendation, moderate evidence). • That triple therapy should be the standard of care and initiated in all children with HIV who are 5-years-old or younger. Older children should start treatment, irrespective of age, at a CD4 threshold of 500. • Recommending that treatment should be offered to all HIV positive people (ie at CD4 counts >500) if they have a sexual relationship with an HIV negative partner (this was carried forward from the 2012 recommendations). • Recommendations for choice of treatment: which drugs to use in first, second and third line combinations. These raise some of the most difficult limitations for the guidelines. The disconnect between continued use of d4T and the thought of early treatment without access to the latest treatment is one of the most important omissions. Hepatitis C: The New Challenge HCV is a highly prevalent chronic viral infection, which poses major public health, economic and social crisis, particularly in low and middle income countries. The global hepatitis C epidemic has been described by the World Health Organization as a 'viral time bomb,' yet continues to receive little attention. Access to preventative services are far too low, while diagnosis and treatment are expensive and remain inaccessible for most people in need. Public and political awareness in regard to hepatitis C are also too low, and national hepatitis surveillance is often non-existent. The hepatitis C virus is highly infectious and is easily transmitted through blood-to-blood contact. It therefore disproportionately impacts people who inject drugs: of the 16 million people who inject drugs around the world, an estimated 10 million are living with hepatitis C. In some of the countries with the harshest drug policies, the majority of people who inject drugs are living with hepatitis C – more than 90 % in places such as Thailand and parts of the Russian Federation. The hepatitis C virus causes debilitating and fatal disease in about a quarter of those who are chronically infected, and is an increasing cause of premature death among people who inject drugs. Globally, most HIV-infected people who inject drugs are also living with the hepatitis C infection. Harm reduction services –such as the provision of sterile needles and syringes and opioid substitution therapy– can effectively prevent hepatitis C transmission among people who inject drugs, provided they are accessible and delivered at the required scale. The Failure of Government Policies Instead of investing in effective prevention and treatment programs to achieve the required coverage, governments continue to waste billions of