Can Certain Contraceptives Increase HIV risk?

I can imagine that those who try to remain current with new developments in contraception and HIV risk reduction may cringe at discovering that something else might place them at increased risk of HIV infection. This time, that something else may be a popular form of contraception, injectable hormones. Injectable hormones, such as the well-known Depo-Provera, are one of the easiest, most cost effective contraception alternatives because they are long lasting, easily administered and and gives women more control over the timing of their pregnancies. Unfortunately, they do not protect against HIV or other sexually transmitted infection. Now, a recent study published in Lancet on October 3, 2011, raises concern that their role in HIV infection might be even more problematic. Researchers from the University of Washington followed almost 4,000 couples for two years in Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia. In each couple, either the man or the woman was already infected with HIV.

The study found that women using hormonal contraception became infected at a rate of almost twice as high compared with those not using that method. Transmission of HIV to men also occurred at a rate almost double from women using hormonal contraception than for those who did not. Two other major ones have also demonstrated increased risk of HIV through the use of injectable contraceptives.

It is not entirely clear why this may be happening. The Progestin in injectable contraceptives may have a physiological effect, such as immunologic changes in the vagina and cervix. Moreover, researchers found more HIV in the vaginal fluid of those using hormonal contraception than those who did not. This might help to explain why men might have increased risk of infection from hormonal contraceptive users.

While the results of this study may be quite sobering, especially to those who use injectible hormonal contraceptives, it is just as important that we remember that for most, HIV risk reduction still remains firmly within our control and underscores the importance of not just knowing one's own HIV status, but that of our partners.

Treatment is Prevention Part 1

Some of you may be aware that the annual HIV Prevention conference has been taking place in Atlanta this week. One of the unique aspects of HIV conferences is that they tend to bring together an eclectic mix of people: consumers, researchers, medical providers, non profits and other assorted advocates. As we, as a society, struggle with finding new and creative ways to reduce the transmission of HIV, it was only natural to consider the impact a medical model might have on this challenge. Perhaps one of the most exciting studies within the last several months demonstrates the benefit of immediate, aggressive HIV treatment in reducing transmission.

Historically, HIV prevention targeted those who were negative. Eventually, more emphasis was placed on "Prevention for Postives," which focused primarily on changing the potentially risky behavior of people who are HIV+. However the promising results of a study, known as HPTN 052,that evaluated whether the immediate use of HAART (Highly Active Anti-retroviral therapy) by HIV-infected individuals would reduce transmission of HIV to their HIV-uninfected partners (which would also potentially benefit the HIV-infected individual), demonstrates the increased role of medical treatmet in prevention. The results of the study were truly groundbreaking: there was a 96 percent reduction in risk of HIV transmission to the HIV-uninfected sexual partners.

The results of this study underscores previous efforts to test as many people as possible by making HIV a routine part of medical care as well as aggressive community mobilization by showing that if we can get HIV+ individuals into care and keep them there, it may reduce overall HIV incidence and save lives. Put another way, this study adds another needed weapon to our arsenal as we continue to make progress if our war against this formidable, entrenched enemy: HIV.

HIV at 30

For the two or three of you (lol) who follow my blog, you may have noticed that I haven't blogged in a while. A lot has happened to me over the last several months that I won't get into now. However, I have returned with a renewed sense of purpose and quite a lot to say.

Much has been written about the 30th anniversary of HIV. I plan to write throughout the year on this topic. It is long and complex area and I cannot begin to do it justice in one or two blogs. So hear I go......

My blog today will be more in the form of a rant. It comes on the heels of a recent radio show on which I appeared. During the show, I experienced a sense of déjà vu; that the conversation I was engaged in has happened before. After 30 years, I was answering many of the same questions, the same way:

* Why are the rates so high in the African Americans so high?
* Whay aren't the churches more involved?
* Why do so many African Americans have conspiracy theories?
* Isn't Magic Johnson cured?
* Why is the stigma so great?
* Isn't AIDS a gay disease occurred to me?

After 30 years, with so many ways to access the information, why hasn't it sunken in? Moreover, this 'HIV illiteracy' does not seemed to be impacted by SES (socio-economic status) I have had the same conversations with people ranging from 6th grade reading levels to doctorates.

Certainly the glass isn't completely empty. We have made strides. There is finally a National HIV strategy. Many cities have instituted robust social marketing and testing intitiatives. And, some faith-based institutions have become involved. But, as I have these daily conversations and watch the rates continue to rise, it still seems apparent that it just hasn't sunken in enough. Without our most important asset, knowledge, we still have a long way to go.

2010- a Year of Promise

For so many years, the news about efforts to combat HIV/AIDS has been, in a word, depressing. It seemed that with every positive development would come news of escalating infection rates, or that some promising vaccine or therapy was less promising than we had hoped. But 2010 will be remembered as one of the first years where there seems to be almost universal optimism that real progress is being made in this war.

Perhaps the most optimistic front has been in the area of science. During this year, we have been uplifted with promising results of studies raging from the possible efficacy of microbicides, to the potential of gene therapy. At the International AIDS Conference, one of the major themes throughout the event was that effective HIV treatment IS prevention i.e., that reducing viral load may be an effective tool in reducing infection rates. Moreover, for many years, the idea of a pill that could prevent HIV infection was almost universally derided. Yet with the recent announcement of the National Institutes for Health study of pre –exposure prophylaxis in MSM, we now may have another tool to reduce infection rates in individuals at greatest risk.

Not all of the positive news has just been in the field of science. Thanks to President Barack Obama, the United States has its first National HIV/AIDS Strategy with an extra 30 million dollars added for HIV prevention (and 25 million for the struggling ADAP program). Moreover, with the reopening of the National AIDS Policy Office, the approval of needle exchange, the elimination of the travel ban for people with HIV and most importantly, the passing of the Affordable Care Act, the United States has finally taken a broad, visible leadership role in fighting this epidemic.

So while there is undoubtedly good news, there also remain challenges. Less than half of the individuals needing HAART are receiving it. Moreover, the global recession has caused historic belt tightening throughout the world. In the United States, many states and cities are either reducing or considering reduction in HIV/AIDS services. Even staunch HIV advocates are reflecting on the monumental task (not to mention the expense) of keeping tens of millions of HIV+ individuals alive with HAART indefinitely, a lifetime cost that a Cornell University study estimated at $600,000 per person.

So where do we go from here? Perhaps the greatest optimism during 2010 has been the belief from many HIV researchers that a cure may be on the horizon. There are several very promising areas of “cure” research with promising results. However, in this case, the ‘devil is not in the details,’ but in the dollars. In order to find a cure, whether a functional one that allows people to maintain an undetectable viral load without medication or an eradication cure, it will take a lot more money then is being expensed now. For example, the cost of researching and developing a single drug has been estimated at 500 million to 2 billion dollars.

The hundred dollar question is: will we demonstrate the commitment, through the economic resources and the will to revamp the infrastructure to facilitate cure and vaccine research, or will we keep looking around and hoping for some lucky, miraculous (and cheap) breakthrough? A wise man once coined the phrase to me that the history of AIDS is still being written. Let’s make this next chapter, 2011, the year where WE gave the bully a bloody nose.

Disturbing New Information on MSM and HIV

One of the most frustrating aspects of working in HIV is addressing the many myths (as well as conspiracy theories) surrounding it-the most persistent of which is that AIDS is a "gay disease." Clearly this myth started early in the history of HIV in the U.S., yet has persisted despite clear evidence of how HIV is transmitted and the growing diversity of those whom become infected. Moreover, it has been convenient for many to affix the label of "gay" to anyone who has had sex with the same gender. However, a startling new report from the Centers for Disease Control (CDC) may add additional fuel to that myth. A CDC study conducted in 21 cities tested over 8,000 gay and bisexual men participating in the 2008 National HIV Behavioral Surveillance System.

The study found that almost one in five men having sex with men (MSM) was infected with HIV and that almost half of them did not know it. Black MSM were infected at a rate of 28%, as compared to 18% for Latino men and 16% for Caucasian MSM. Black MSM were even less likely to know their status than other races (59% were unaware) with young black MSM, a shocking 71% of which were unaware of their status. There was also a high co-morbidity with HIV status and socioeconomic variables-with HIV + status increasing as education and income decreased.

Studies such as these point to the glaring need for new creative strategies, not to mention social marketing approaches, to attract more and younger MSM to get tested. Moreover, despite all of the hoopla about '"men on the down low" as the culprit for rising infection rates with women, we cannot overlook the fact that many of the men in this study were bisexual and therefore, may have female partners. Previous studies have shown us that when someone knows their HIV status they are more likely to practice safer sex. Hopefully a renewed focus on HIV prevention targeting MSM may lead to a sorely need national dialogue revealing the diversity and complexity of the topic. Perhaps that discussion will help dispel the myth.

HIV may have been present for 32,000 years

Despite the persistent myth that HIV was a man-made disease, unleashed upon the unsuspecting, disenfranchised of our society (read gays and blacks), now comes more evidence that it may have been present in monkeys and apes for a millennia. New research, published in Science magazine last month, report the presence of the ancestor of the simian HIV virus in Africa possibly dating back as far as 78,000 years. This fascinating research, that studied monkey species on a volcanic island off of the coast of West Africa, who developed in isolation, found that four of the six species had been infected with HIV.

Although this study may help to answer certain questions, such as why HIV infects most simian species, but doesn't kill them, it fails to answer the main one: how did a relatively benign monkey virus become one of the greatest health crises in the history of mankind. Many still believe that the human HIV epidemic was caused by, purposely or inadvertently, human meddling.

Evidence of the great age of HIV does point to the likelihood that, over centuries, the virus killed off weaker monkeys leaving behind those who became resistant to it. However, does that mean that it will take thousands of years before we are able to adapt naturally to HIV? Can we survive that long with rising rates, declining government support and the aggressive mutation of the virus?

Our obvious advantage is, of course, our technological superiority. We now have over 30 medications to treat HIV and many believe that a cure is still possible. However, by following the path of HIV and other diseases, it hopefully reminds us of our fragility and vulnerability as we continue, sometimes in the interest of capitalism and expansion, to invade more exotic and isolated lands and interact with previously unknown species.

Opt-Out and Eliminating Consent for HIV Testing

President Obama's new AIDS Strategy calls for a renewed effort to reduce new HIV infections by 25%, increasing the number of people who know their status from 79% to 90%. Crucial to the success of this benchmark is to test more people for HIV. This is consistent with the Center for Disease Control's recent recommendations (in 2006) to encourage HIV testing to become a routine part of medical care. However, one of the more controversial aspects of this push is the distinction between 'opt -in' vs 'opt-out HIV testing. Opt-in testing generally refers to an opportunity for the patient to be asked, by a provider, if s/he would like to be tested for HIV. Opt-out testing means that a patient will be given an HIV test unless s/he chooses not to have one. The CDC has recommended opt-out testing as well as the elimination of written consent (a medical consent form that authorizes HIV testing).

As one might imagine, this is a pretty contentious topic, even among HIV advocates and medical providers. Supporters of opt -in testing and informed consent argue that people need to understand what they are being tested for and why. Moreover, they argue that eliminating written, or even verbal consent fails to address the reasons why so many people fail to be tested, at the expense of expediency. Ignorance, apathy, stigma and discrimination are still alive and well, they claim, and cannot be ignored. Opt-out testing proponents point to the growing members of people who do not know their HIV status, present for treatment in the latter stages of their disease and the glaring disparity of HIV among the poor and communities of color as evidence that the present system isn't working and that we need new strategies to address the soaring epidemic. They also minimize the impact of stigma and discrimination, due in part to the efforts to make HIV testing more routine.

Nowhere is this debate raging more than in New York City, which still hold the crown for the highest incidence of HIV of any US city. New York State requires written consent, but the current policy is being reexamined. So what is the right policy? One thing is clear: both sides seem to be focused on the same outcome, a reduction of HIV infection. Unfortunately, in an era of dwindling resources it is sad that there is not more consensus on this issue. What isn't clear if if the present policies around informed consent aren't working. There is evidence that many medical providers are not offering HIV testing to their patients, due in part to their discomfort with the subject. Moreover, there is evidence, some of which comes from New York itself that HIV testing is rising under the current rules.

I am concerned that if people are not given an opportunity for consent for HIV testing and to have the conversation that would likely take place with that medical provider, that much of the ignorance and misconceptions about HIV will remain. Moreover, if provider feel a conversation about HIV testing is uncomfortable, then how will they feel about giving someone a positive result? We clearly have a long way to go before our society sees HIV/AIDS as just a medical condition. Before eliminating informed consent, I feel that more training for medical providers, more and robust social marketing to reduce HIV stigma and a renewed emphasis to ensure that HIV testing is being offered in routine medical settings are more effective measures to increase HIV testing.