Compiled by Martin Flynn
As many as 80 per cent of HIV positive people suffer from depression, according to a recent US study reported at this summer’s AIDS Impact Conference in Marseilles.
British AIDS activist and journalist Michael Carter told the meeting of the link between mental health and HIV.Toxicities and side effects to HIV medications, such as lipodystrophy and sexual dysfunction, make the situation worse for people living long-term with the disease, he said.
Sexual dysfunction is known to affect up to 70 per cent of people living with HIV, Mr Carter claimed, and in 2000 at one major London clinic, 13 per cent of all referrals were due to sexual dysfunction.
Depression is a major reason why people not only have unsafe sex, but also why they do not get tested or do not take their medications.High rates of undiagnosed depression among people with HIV has a deep impact on both mental health and HIV drug adherence.Stigma and discrimination by society as a whole is still present, he said, and the culture of blame puts more pressure of HIV positive individuals.
“People are becoming more prejudiced against people with HIV than ever before,” Mr Carter added, “even within the gay community.”
Four transplant recipients at three Chicago hospitals have contracted HIV and hepatitis C from a single organ donor, US health officials said. The cases mark the first incidence of HIV infection contracted from organ donation in more than 20 years, according to Dr. Matthew Kuehnert, who oversees organ safety at the US Centers for Disease Control and Prevention.
Kuehnert said outside testing has confirmed that both the donor and all four transplant recipients have tested positive for both HIV and hepatitis C.
“It is very unlikely that all four would be infected with HIV and hepatitis C by chance,” Kuehnert said in a telephone interview. He said the CDC is conducting its own tests to match the strain of HIV in the donor with the infected recipients and to determine the best course of treatment.
Hospital officials confirmed that two patients at the University of Chicago Medical Center, one patient at Northwestern Memorial Hospital and one at Rush University Medical Center tested positive for HIV or human immunodeficiency virus, which causes AIDS.
“All of the policies were followed correctly and all of the tests were done correctly. Unfortunately, the tests came back as a false negative result,” said Mandy Claggett, a spokeswoman for United Network for Organ Sharing or UNOS, which sets policy for organ donation and has been monitoring the investigation. Kuehnert said the organs came from a high-risk donor, meaning from someone who fit under one of several criteria that would increase the chances that the person might have be infected with HIV. Those include men who have had sex with another man in the preceding five years, intravenous drug users, prisoners, and people who have had sex for money or drugs.
>HIV drugs are too expensive and too complex for people with HIV in poor countries in sub Saharan Africa and HIV prevention is a more priority than treatment, according to Dr Joep Lange, of the Netherlands.
Speaking at the EACS conference in Madrid, Dr Lange said that with nearly 40 million now living with HIV and over 4 million new infections each year, we are in danger of losing the prevention battle.
For every six new infections only one is being treated, he said.
In the rich western world the demand for more simplified treatments and prevention of disease complications and side effects is the most important challenge but in poor countries of Africa two thirds of people who need treatments are not getting them.
Over 800,000 people with HIV are now on treatments in sub Saharan Africa and the ‘3 by 5’ target to get 3 million on treatments by 2005 has, “had a very important influence on reaching targets, but universal access is another pipe dream,” Dr Lange said.
In Africa there is reliance on first line and toxic drug therapies and there are constant problems of interrupted supply, limited second line treatment options and very limited monitoring capacity. There is a lack of effective prevention, information and even condoms.“Only three condoms per man per year are available in sub Saharan Africa.”
Searches for an HIV vaccine have so far failed, and prevention alternatives like microbicides, diaphragms and circumcision have so far had limited success because of cost or cultural problems. And there is an urgent need for new prevention methods.“We are now reaching the point where an emergency response will not do,” Dr Lange said.“Even though there are good international funding mechanisms for HIV now these won’t last, he predicted. “We have no problems getting mobile phones and Coca Cola to Africa, so why can’t we get urgently needed antiretrovirals to everyone?”
Investment in healthcare in Africa is very low, and health insurance is almost non existent. Dr Lange called for better financial and health sustainability for Africa, rather than charity, and said the countries profiting from Africa’s plight were the rich countries of the west.
Professor Jurgen Rockstroh, from Germany, said that in some countries, like his own, HIV prevention was working well but there was an urgent need to target high risk groups.“People are coming into the clinics for sexually transmitted infections and finding out they have HIV.” He added: “We have to think how we can engage people in a different way”.
Professor Anton Pozniak, from London’s Chelsea and Westminster hospital, admitted that prevention was failing but said there is not one answer. “Youth of today have to be addressed on sex, STIs and HIV.” New prevention techniques like circumcision can cut infections rates by more than a half but they are not for all and may not be the best methods.
EACS conference chair Professor Santiago Moreno, of Spain, said that for HIV prevention to work implies changing life habits and behaviour.“People know how to prevent HIV but they don’t like to change their lifestyles.” Professor Moreno said the burden of the disease is rising exponentially and predicted that in a few years time the cost of the epidemic will not even be affordable in the rich developed world.
HIV is increasingly becoming a problem for older people and growing old with the disease is leading to more and different medical and social challenges.
In the clearest and most amusing presentation to the Madrid EACS conference, Dr Bernard Hirschel, of Switzerland, said that in 1998 only five per cent of HIV patients were over 50 but in 2007 that percentage had now gone up to 25 per cent.
Dr Hirschel highlighted some of the problems of older people with HIV and said there was some research indicating more sexual risk taking in older gay men.
He was now treating much bigger numbers of older patients with the disease and said he had just diagnosed and successfully treated a woman in her 80s.
The so called ‘Viagra generation’ needed specific HIV prevention messages, he said.
Whereas rates of AIDS defining cancers had gone right down since the era of HAART (Highly Active Antiretroviral Therapy), rates of non Aids defining cancers had gone right up. And all non AIDS defining cancers are now three times more common in the HIV positive population that among HIV people.
The most common cancers now being seen in older HIV positive people are lung, prostate, anal, liver and Hodgkins cancers. “HIV positive people are more likely to smoke than the general population and if you add in age as a factor then more and more HIV positive people will be getting ill and dying from lung cancer,” Dr Hirschel predicted. There are also higher risks of cardiovascular (CV) disease in older HIV positive people and smoking triples the risk.
The ten year risk is two per cent in women but 10 per cent in men and with higher blood pressure and high cholesterol levels that risk gets worse.
Dr Hirschel debated the relationship between HIV and dementia and said there were similarities between Alzheimers disease and AIDS Related Dementia (ARD), brain atrophy and brain cancers.
Because HIV drugs can cross the blood brain barrier there may be protective against degenerative brain diseases as HIV people grow older. The good news is that older individuals are generally more compliant or adherent to HIV therapies than younger individuals.“And it’s your job as physicians to ensure that your patients die of something apart from HIV.” Dr Hirschel added: “But remember that life is a sexually transmitted disease with one hundred per cent mortality.”.
Dr Jacqueline Capeau, of France, posed the question whether HIV therapy affects normal ageing. Accelerated ageing is common in HIV positive people and some HIV treatments have now been shown to accelerate DNA damage and early cell death leading to a wide range of degenerative diseases.
Professor William Powderly, of University College Dublin, said we can’t change our sex, age or history but we can greatly lower our risk of cardiovascular disease by stopping smoking. As many as 50 per cent of HIV positive people smoke, he said, and many have higher triglyceride and cholesterol levels, diabetes and hypertension. Each five years of age increases the risk by 39 per cent.
HIV clinics should routinely address the specific health needs of older patients but diet, exercise and lifestyle changes can prolong life. “Just stopping smoking reduces the risk of cardiovascular disease from 20 to 8 per cent in the next ten years,” Professor Powderly said: “The impact of smoking cessation is greater than anything we can do.” And treating raised lipids and hypertension aggressively can also improve long term health and prevent the risk of heart disease as we get older.
Dr Corine Isnard Bagnis, of France, spoke about kidney disease and HIV and said that people of African descent are much more likely to get renal problems.
Being exposed to multiple drug therapies, having hypertension or diabetes or liver disease all contribute to greater risk of renal disease as we get older.
“Acute renal failure rates did not decrease in HIV patients between 1993 and 2003,” she said. Dr Bagnis called on HIV doctors to monitor renal function regularly in all HIV patients. She also asked doctors to be extra careful with drug doses and prescriptions and revealed that one German study had revealed 25 per cent prescription errors in HIV. “We often see patients who have not been given the appropriate level of their antiretroviral drugs,” Dr Bagnis added.
The treatment for cancers among HIV patients has improved, Dr Christian Hoffman, of Germany told the EACS conference but the survival rates are not as good as for HIV negative patients. And the survival rate for smokers with HIV who get lung cancer is just 30 per cent in a year, he said. Many of the cancers are preventable, he said, and he called for regular clinic screening for anal cancer with anal PAP smears. But the use of antiretroviral drugs has not been shown to worsen cancer rates or treatment outcomes. Co-infection with Hepatitis B or C greatly increases the risk of liver cancer. “Cancers remain a significant factor for mortality,” Dr Hoffman concluded.
Sixty per cent in Europe don’t know they are
HIV positive
The latest data from the World Health Organisation (WHO) reveals that 60 per cent of people with HIV in Europe are undiagnosed and don’t know they have the disease.Dr Jens Lundgren, from Copenhagen, explained the shocking news at the European AIDS Clinical Society (EACS) conference held in Madrid in October.
In Britain the percentage of people who don’t know they have HIV is about a third but in Russia and Ukraine the percentage is as much as 90 per cent, he said.
WHO data also reveals that in 2005 over 80 per cent of people with HIV in Western Europe were on HAART (Highly Active Antiretroviral Therapy) but only 8 per cent in eastern Europe.“HIV is still the key public health problem across Europe,” Dr Lundgren said.
‘You can’t hide lipoatrophy’
Severe fat loss in the arms, legs, feet and face, known as lipoatrophy, is very stigmatising and affects both behaviour and psychological well being.
This was the stark conclusion of Dr Giovanni Guaraldi, speaking at the EACS Madrid conference. Dr Guaraldi runs a metabolic clinic for lipoatrophy in Modena in Italy and he explained that he tries to listen to his patients and treat the problem.
“You can’t hide lipoatropy,” he said, and it affects quality of life, anxiety and depression as well as sexual dysfunction.
A study of 350 HIV positive men at his clinic revealed over half had impairment of sexual function, body image and mental health problems.
“The higher your adherence the higher your chances of getting lipoatropy,” Dr Guaraldi said.A range of medical and psychological support services are now available in Italy for people with the side effect. “For some patients surgery was the cure for their depression.” The Modena Clinic has produced a powerful video to explain the impact of lipoatrophy which can be viewed at www.lipodistrofia.info.
“We blamed protease inhibitors for lipoatrophy for a long time but this was not true.”
Dr Anton Pozniak, of the Chelsea and Westminster Hospital, said. Dr Pozniak explained that it is now possible to switch from the HIV drugs which lead to lipoatropy, the thymidine analogues such as AZT, ddI and D4T, onto drugs which can stop or even partially reverse the fat loss.“The thymidine analogues have now been eclipsed,” Dr Pozniak said.
UK activist Winnie Ssayu Sseruma, from the African HIV Policy Network (AHPN), said that a UK survey had revealed that two thirds of HIV positive people would be prepared to lose more than a year of life if they could avoid lipoatrophy.
Winnie explained her own 20 year battle with HIV and stressed the importance of building up a good relationship between doctors and patients.
She advised HIV patients to be proactive and to keep a patient journal, prepare for hospital appointments, take an interest in their health, get involved in their clinic, build up a relationship with their doctor, work with advocates and also get support from friends and family.HIV patients who have a good relationship with their doctors are more likely to adhere to treatments and get better outcomes, Winnie said.
Words from around the World
“The perception of people living with HIV and AIDS by the general public is still negative.”
Dr Bruno Spire, AIDES, France.
“Fifty per cent of new HIV infections are from people who are newly infected themselves. How can you blame someone who doesn’t know they are HIV positive?”
Dr Mark Wainberg, McGill University, Canada.
“We have a comfortable AIDS industry that supports itself and needs to become more accountable.”
Professor Helen Rees, South Africa.
“HIV disclosure is a moral act. ‘Don’t ask, don’t tell’ only increases stigma for people with HIV. There is a sense of duty to disclose.”
Dr Peter Keogh, Sigma Research, University of Portsmouth.
“Hepatitis C (HCV) is the big new elephant in the room. HCV is more stigmatised in the gay community than HIV. The fear of rejection and stigma is even worse than the disease itself. I felt grubby and skanky. There is a belief that dirty men get HIV or HCV.”
Michael Carter, NAM.
“Even in western countries large of people only find out their HIV positive status when they develop serious opportunistic infections.”
Dr Kevin de Cock, World Health Organisation (WHO).
Words from
around the World
continued
“TB is the biggest cause of death from a curable infectious disease.”
Dr Matteo Zignol, WHO Switzerland.
“The HIV and AIDS epidemic has taught us the value of solidarity, commitment and hope.”
Dr Teresa Robledo, secretary of the Spanish National Plan on AIDS.
“Treatments are currently started too late in Europe.”
Dr Jens Lundgren, Copenhagen.
“The NHS currently spends £200 million per annum on antiretrovirals.”
Robert Fieldhouse, treatment activist and writer.
“Far less progress has been made for children with HIV than for adults.”
Dr Valerie Stone, Harvard University Medical School.
“Twenty five per cent of HIV patients in Britain are starting treatments without resistance tests. If HIV treatment was a Smartie then everyone would start treatment as soon as they are diagnosed.”
Simon Collins, HIV i-Base.
“Within 10 days of HIV infection you lose all the lymphocytes in the gut and you never get them back.”
Dr Mark Nelson, Chelsea and Westminster Hospital.
USA STDs on the rise
The rates of three leading sexually transmitted diseases - chlamydia, gonorrhea and syphilis - rose again in the United States last year, worried public health officials have reported.
It was the second year in a row of increases for all three of these sexually transmitted bacterial infections, the Centers for Disease Control and Prevention said. The rate of chlamydia, the most common infectious disease reported to the CDC, increased 5.6 percent in 2006 from 2005.
