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HIV Epidemiology

Sexually transmitted infections are amongst the fastest spreading high-incidence notifiable diseases in China

31 May, 17 | by Leslie Goode, Blogmaster

Sexually transmitted infections emerge from a recent epidemiological study as a particularly pressing concern for Chinese public health at the present time.  Yang & Li (Y&L) assess trends in incidence and mortality in 45 notifiable infectious diseases across China over the decade since the SARS tragedy in 2003 brought important changes in Chinese public health strategies (2003-2013). The main interest of the authors is to investigate the effectiveness of the new strategies.  But, for readers of this journal, what will be especially interesting about this study is the unique profile of three sexually transmitted – or potentially sexually transmitted – diseases: syphilis, HCV and HIV.

In terms of current incidence these three occupy 6th, 8th, and 15th place among the 45, with yearly incidence per 100,000 of, respectively, 20.75, 9.33, and 3.11.  In respect to mortality, HIV far outstrips all the others (even TB), with 48,199 deaths over the ten year period.  However, syphilis, HCV and HIV differ from other high-incidence diseases – hepatitis B, TB, mumps and bacterial dysentery (respectively, 2nd to 5th in the incidence table) – in that their year-on-year incidence is increasing, and at an impressive rate (estimated at a yearly 16.3%, 19.2% and 16.3% averaged over the decade).  These increases are unparalled except in the case of hand, foot and mouth.  The trend in STI incidence emerges particularly strongly against the background of overall trends in the other notifiable diseases. These have, on the whole, been towards stabilization in the latter half of the decade (2009-2013), following an earlier rise likely due in part to technological progress in laboratory detection and case identification (2003-2009).

This raises the questions whether, in the case of STIs, there are particular social factors at work.

For the authors of the study, syphilis, HCV and HIV fall into the category of those diseases whose recent spread can be attributed to the enormous demographic upheavals that have brought over 10% of the population from poor rural areas to the big urban centres in search of economic opportunities, and to ‘augmented human connectivity’.  As regards population mobility, the opinion of Y&L is corroborated by Chen & Tucker (STIs), and – in the case of MSM populations – by Yu & Shang (STIs).  Interestingly, Y&S identify a class of ‘recent migrants’ to the big cities, whose risk profile appears to differ very considerably from that of longer-term residents. Young FSM – many of them also recent migrants to urban centres – appear to represent another high-risk group (Zhang & Luchters (STIs)).  As for the related factor of ‘augmented human connectivity’, this has also been strongly corroborated (Tang & Tucker (STIs)).  Other studies, however, have traced regional outbreaks in these infections – syphilis, HCV and HIV – to causes that are less obviously linked to recent demographic change.  Zhang & Tang (STIs), for example, emphasize the part played in Guangxi by female sex workers who are patronized by older rural workers.  Epidemiological factors, especially over such a vast area, will obviously be complex and multifactorial.

 

Location of HIV-2 emergence determined by distribution of indigenous cultural practices of male circumcision

16 Jan, 17 | by Leslie Goode, Blogmaster

Sousa & Vandamme demonstrate a robust correlation between HIV-2 prevalence at the time of the 1980s surveys and the absence of indigenous practices of male circumcision earlier in the century.  This is a complex and interdisciplinary study, involving some of the earliest large-scale, West African serological surveys of HIV-2 (1980s) and extensive ethnography of the region throughout the twentieth century.

HIV-2 seems to have crossed the species barrier into humans from a primate called the ‘sooty mangabey’.  The two epicentres of the 1980s HIV-2 epidemic – south-west Côte I’Ivoire and Guinea Bissau – correspond to the two points along the band of sooty mangabey territory where ethnic groups were to be found who did not practice circumcision (Côte I’Ivoire), or performed it only late in life or very intermittently (Guinea Bissau).  The complexity of this study arises from the fact that, thanks to waves of islamicization, male circumcision has been widely adopted across the region even in areas where it was traditionally prohibited.  Hence investigation of the correlation with HIV-2 emergence, probably in the 1940s, required the authors to go back to ethnographic accounts preceding islamicization.

Of course, the certainty of a causal link cannot be established.  But Sousa & Vandamme discover a strong negative correlation between male circumcision and HIV-2 (Spearman rho = -0.546).  Their results are supported by studies that establish the same negative relationship with HIV-1, both in sub-Saharan Africa (Moses and Plummer) and, more recently in Papua New Guinea (MacLaren & Vallely/STIs).  A likely causative mechanism might be the prevalence of ulcerative sexually transmitted infections (Weiss & Hayes/STIs).

So Sousa & Vandamme offer an additional ‘ecological’ reinforcement of the public health rationale for encouraging voluntary male medical circumcision (VMMC).  Yet what is also interesting, from a public health perspective, is the importance their study attributes to culture in the adoption of a practice like male circumcision.  In the present case, for once, the impact would appear to have been very positive from the medical point of view. The authors speak, for example, of islamicization, along with ethnic intermarriage in the cities, as having given rise to ‘social pressure to be circumcised in order to be accepted by women’, and the ‘abandonment of traditional prohibitions of male circumcision’. Of course, the impact of indigenous culture may often be less benign from a medical point of view – as the source of conservative attitudes that tend to hold back and limit the uptake of VMMC.  As, for example, where males have seen male circumcision as the practice of potentially hostile neighbouring groups (Cultural constraints on uptake of circumcision/STI/blogs), or as a practice uniquely suited to those younger age groups on whom it was traditionally performed (Mbabazi/STIs).  But, either way, it is noteworthy that the influence of local culture would often seem to be so decisive.  So there may be an argument, for electing to promote infant circumcision, as an evidently medical practice that runs less risk of falling foul of prevailing cultural attitudes that restrict ‘demand’ (Gray & Kigozi/STIs; Feasibility of infant circumcision/STIs/blogs).

 

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UNAIDS 2016 Report: How a ‘life-cycle’ approach can help the world ‘get on the fast track’ to HIV prevention

7 Dec, 16 | by Leslie Goode, Blogmaster

‘Get on the Fast Track: a Life-cycle Approach to HIV’ is the latest UNAIDS report, following on from the UN Assembly’s 2016 declaration of commitment to ‘Fast Track’ goals for ending the HIV/AIDS epidemic. The major theme of the ‘life-cycle’ appears to owe much to the findings of the South African CAPRISA study – above all, the idea of a transmission cycle between younger (25 year-old) women and older (>25 year-old) men.  Broadly, phylogenetic analysis reveals that the prevailing pattern of transmission is as follows.  Younger women appear to get infected through casual relationships with considerably older men, who have, in turn, been infected by their longer-term partners; in time, the younger women grow up and form longer-term relationships – and the cycle is repeated.  The former group – younger (≤25 year-old) women – appear to be more vulnerable to infection than men of the equivalent age due to complex social factors, and have recently seen only c. 6% declines in annual incidence; older (>25 year-old) men have incidence rates that have remained obstinately high despite all recent efforts to reduce them.  These are best explained by poor rates of testing, integration into treatment, and viral suppression making them a potential risk to non-HIV-infected partners.

Diagnosing a problem is one thing; framing the solution quite another.  In case of the younger women, the dominant factors appear to be structural and societal – e.g. gender inequalities.  These are difficult to address without major social and political change.  The authors suggest a number of prevention tools, including sexual education in schools, the introduction of pre-exposure prophylaxis (PrEP), and social transfers.  However, recent trials of PrEP in sub-Saharan Africa do not bode well for this intervention (STI/blogs/’Failed PrEP trial’; STI/blogs/‘Another failed PrEP trial’); while the evidence for the effectiveness of sexuality education and ‘social transfers’ is far from conclusive (School-based Sexuality Programmes/STI/blogs; STI/Galarraga & Sosa-Rubi; STI/Minnis & Padian; STI/Khan & Khan).  However, in the case of the other group – i.e. older men – the obstacles to HIV prevention (poor rates of testing and viral suppression) may be less intractable, and the report proposes a number of very practical measures that could help, including: distribution of self-test kits through female partners attending ante-natal clinics (STI/blogs/’Partner-delivered STI testing’); simplifying ART regimens so individuals have to take just one tablet a day; shifting from CD4 count testing to viral load testing.

The report also has much to say about other phases of the life-cycle, as well as about ‘key populations’ (estimated 45% of new infections).  Regarding the latter, the authors report the stability, or even rise, in new infections amongst sex-workers, drug-users and MSM. They emphasize the negative impact of criminalization of key populations and same-sex relations (73 countries) (see STI/blog/’HIV criminalization’/; STI/blog/’Health workers violate human rights’), the very low levels of domestic funding (on average, only 12% of total spending on MSM prevention), and the relatively young age of many in the ‘key populations’.  The authors recommend ‘comprehensive’ programmes for these populations incorporating access to a range of health care programmes, such as the Red Umbrella programme for sex workers in South African, and the ‘Targeted Strategy Plan’ for the transgender population in Lima, Peru.

 

Where next for HIV prevention in New Zealand?

29 Jan, 16 | by Leslie Goode, Blogmaster

A recent issue of the New Zealand Medical Journal (NZMJ) (128: vol. 1426) gives pride of place to a series of papers that reconsider the way forward for HIV prevention in New Zealand (NZ) against the background of the past thirty years.  Recent contributions to STI journal by these authors analyse the behavioural surveillance data from NZ (Saxton & Hughes (STIs); Lachowsky & Summerlee (STIs); Lachowsky & Dewey (STIs)); the papers in NZMJ set these findings against a broader background (Saxton & Giola; Hughes & Saxton; Dickson & Saxton; Saxton & Ludlam).

Broadly speaking, the situation in NZ resembles, both in nature and scale, what we find in Western European countries: namely, persistent but relatively low-level epidemics concentrated in the MSM population (above all, in Auckland), and among heterosexual individuals of foreign extraction (Dickson & Saxton).

The distinctiveness of the NZ epidemics, as against those of Western Europe, lies primarily in geo-political factors: such as migration from sub-Saharan Africa, which reached a peak in 2006 before abruptly declining – or the changing demography of Auckland with its large populations of South Asians and people of Pacific origin (Dickson & Saxton: Lachowsky & Summerlee (STIs)).  The main emphasis of the NZMJ papers, however, is on issues that will have a familiar ring to West European readers – such as the importance of achieving a balance between public health and clinic-based approaches to HIV control.

Overall, their account suggests some considerable degree of success on the part of health interventions – but in the face of a public health challenge that is constantly evolving and may yet prove intractable.  As regards the success, some behavioural surveillance data indicate levels of condom use with casual partners of 85% (Hughes & Saxton; Saxton & Hughes (STIs));  The challenge is represented by the growing minority who do not perceive HIV as a threat on account of new treatments (Hughes & Saxton; Saxton & Ludlam). There also remain, as elsewhere, the problems of high levels of undiagnosed HIV (c. 20%) and relatively late presentation to health services (over a third of MSM at CD4=<350/mm3).  A things stand, the worst kind of scenarios seen amongst gay communities in Thailand or the US would appear to have been averted.  Nevertheless, the epidemics show every sign of persisting, and, given a level of diagnosis that it is marginally higher than seen hitherto, may still turn out to be on an upward trajectory.

A key focus of the NZMJ editorial (Saxton & Giola) is on the continued importance of behaviour-based interventions in a world where the momentum seems to have shifted to clinic based control involving pharmaceuticals.  They highlight the danger that the medicalization of HIV prevention could lead to a disinvestment in behaviour-based interventions, which, they imply, would not be conducive to controlling the epidemic.   In this regard, the authors cite Phillips & Cambiano who argue that a mere 10% reduction in condom use would, without improvements in testing levels and ART initiation, result in a doubling of HIV incidence over 15 years.

Myth or reality? Are social media triggering an explosion in sexually transmitted infections?

23 Jul, 15 | by Leslie Goode, Blogmaster

On the whole, where STIs are concerned, social media have tended to be considered as a potential force for the good in public health, offering a new resource for the management of HIV patients, or opportunities for disseminating health messages via peer education (Swanton & Mullan (STIs); Peer group education (STIs/blog)).  Recently, however, there have been a number of studies that have drawn attention to the negative implications of social media.  Last June a study by Beymer & Morisky (STIs), based on data on MSM attendees at the Los Angeles Gay and Lesbian Centre, concluded that, among the 7,000 participants, those who had used geo-sexual networking apps to meet up with a partner had greater odds for testing positive for gonorrhoea (OR 1.25) or chlamydia (OR 1.37) than those who employed in-person methods.

Recently, this more negative side has been receiving ever more attention in the US, especially in connection with HIV transmission.  A yet unpublished but widely publicized study, Agarwal and Greenwood (A&G), investigates hospital attendances for asymptomatic HIV (including acute and silent phases of the infection)  in Florida over the period 2002-2006 when the piece-meal introduction of the digital commerce platform, Craigslist, appears to have greatly facilitated on-line social transactions through its “casual encounters” forum.  It has also offered researchers the chance to record what they describe as a “natural experiment”, as successive counties have experienced the effects of entry into the platform.  A&G estimate the health “penalty” of entry into Craigslist at a 13.5% increase in attributable HIV infections – equivalent in financial terms to an additional burden of $592 million on the State of Florida.   This finding has recently been cited in connection with the precipitous rise in STIs in Rhode Island recently reported in an official Rhode Island Goverment press release and in the press coverage (Huffington Post) – 79% in syphilis; 30% in gonorrhoea; 33% in HIV over the year 2013-2014.

But A&G are concerned with more than estimating the magnitude of the effect.   The recent paper also claims to be the first study to attempt to determine exactly where that penalty of increased HIV infection due to social networking is actually falling – a question that is evidently of great interest to public health specialists who need to be able to target their interventions.  On the face of it, this is something of a puzzle.  HIV appears to be most heavily concentrated amongst the very sectors of the population who are most digitally disadvantaged.  So what could be going on?  To answer this question, A&G seek to disaggregate the Craigslist effect by ethnicity, income-level (as determined by enrolment in Medicaid) and gender.  What emerges from their analysis is that the effect of Craigslist entry is contained almost exclusively within the Afro-Caribbean (as opposed to Latino or “Caucasian”) population.  A&G seek to explain this apparently disproportionate penalty accruing to the digitally disadvantaged.  They argue that the “digital divide” is probably not “binary”, but more like a continuum.  We should not, in other words, necessarily think of “digital disadvantage” – at least for an important proportion of the disadvantaged – in terms of the total absence of access or skill.  It is therefore conceivable that it should be associated with a negative effect, i.e. the increased HIV incidence following Craigslist entry.  “Digital disadvantage”, they argue, is likely to be a matter of the limited capacity to utilize on-line resources for “welfare-enhancing activities” rather than a total unavailability of those resources.

 

Increased HIV infectivity in the acute phase of infection may be a less important factor in HIV transmission than we thought

12 Jun, 15 | by Leslie Goode, Blogmaster

Assessing, as far as we can, the preventative impact of ART on HIV transmission dynamics is evidently very important – both to inform judgments about ART initiation (Wayal & Hart (STI); Cohen (STI)), and also, at the policy level, to be able to evaluate the possible preventative gains of ART scale-up (Shafer & White (STI); Boily & Mishra (STI)).   One important piece of the jigsaw is the impact of ART on sexual behaviour.  This has been discussed by a number of recent studies (Wayal & Hart (STI); Hogben & Ford (STI); Shafer & White (STI)).  Another piece of the jigsaw is the impact of ART on HIV infectivity.  Of particular concern here are the relatively high levels of infectivity that occur in the period immediately after infection.  In view of this, investigators have stressed the importance of the earliest possible initiation of therapy, if the full preventative benefits of ART are to be enjoyed (Cohen (STI)).

The recent study, Bellan & Meyers (B&M), addresses itself to this second, important but potentially less easily investigable piece of the jigsaw. They observe that investigators have tended to proceed on the basis of the known relationship between viral load and infectivity. Empirical evidence of relative infectivity of acute versus chronic phases of the infection is practically unobtainable, for various reasons.  For a start, newly-infected individuals are rarely diagnosed in the acute phase and, if infected by stable partners may provide no evidence on onward tradition; if susceptible non-infected partners are at risk, then, clearly, ethical guidelines dictate that further transmission be stopped – not investigated.  According to B&M, most subsequent studies have relied for direct epidemiological measurement of acute phase infectivity and duration on a retrospective cohort in Rakai, Uganda (Wawer & Quinn; Hollingsworth & Fraser). B&M reassess previous analyses of this evidence.  They find significant bias – especially in two areas.  The first has to do with the neglect of the contribution to total risk of couples who were censored from the cohort owing to couple dissolution, loss to follow-up or study termination.  The second concerns the extent to which some of the estimated difference in risk between the acute and chronic phases may reflect heterogeneity in the risk behaviour of those couples entering the study sero-discordant, as against those entering it sero-concordant negative.

The findings of B&M are intriguing. They argue that combined effect of these sources of bias in earlier analysis of the Rakai evidence has been enormously to inflate estimates of relative acute phase – relative to chronic phase – HIV infectivity. B&M estimate the relative hazard of transmission during acute phase at 5.3, the acute phase duration at 1.7 months, and the “extra-hazard months” contributed by the acute phase (a measure adopted by the authors in order to ensure comparability of study results) at 8.4. Previous estimates give levels of increased infectivity due to acute phase which are equivalent to between 31 and 141 hazard months. If the results of B&M are confirmed in subsequent studies, the preventative gains of ART scale-up could be greater than hitherto supposed.

The varied nature of the US HIV/AIDS epidemic: what makes the South so different?

27 Feb, 15 | by Leslie Goode, Blogmaster

As of 2011, 38% of all US citizens diagnosed with HIV were from a block of nine states in the south-east, sometimes referred to as “the South”: Louisiana, Alabama, Florida, N. and S. Carolina, Georgia, Texas, Mississippi and Tennessee. Death rates among those living with HIV in this region were, by far, the highest of any US region.  A recent study (Reif & Wilson) uses CDC HIV surveillance data to seek to assign characteristics to the large number of persons in that region diagnosed with, and frequently failing to survive, HIV/AIDS, in order to determine what it is about this region of the US that makes it peculiarly vulnerable to the epidemic.

A number of these characteristics were not specific to the South, but shared by all the southern states: the high proportion of those diagnosed who are female (27%: US average 20.9%), who have contracted HIV through hetero-sexual relations (14.5%: US average 11.7%) and who fall in the 13-24 yr age group. What differentiates the South more particularly, is the considerably higher percentages of diagnoses among those living in rural (11%) and suburban (17%) areas, though even urban rates (29.6 per 100,000) are higher in the South than in other regions.  Five-year survival following AIDS diagnosis, at 73%, is considerably lower than the US average (77%), and lower than for any other region. Survival rates following HIV diagnosis were considerably lower for rural (82%) than for urban (86%) areas.  Above all, the death, rate at 27.3 per 1000, was considerably higher than in any other region of the US. (HIV mortality in the UK fell from 21.8 to 8.2 per 1000 over the years 1997-2008 (Smith & Delpech (STI))).

The high death rates for the South suggest, the authors claim, a fundamental “disconnect” between diagnosis and maintenance of care in the region. Moreover, when the figures are adjusted to take account of characteristics of individuals living with HIV, including sex, race, mode of transmission etc., the disparity remains substantively unchanged or accentuated. This likely indicates underlying structural factors affecting the states of the South.  Obvious candidates would be lower insurance coverage, lower levels of income and education. On the basis of the convergence of high death rates and the high proportion of rural and suburban HIV cases in the region, the authors also evoke, more speculatively, the “class system unique to the US South” which has traditionally allowed little social mobility.  They argue this may have contributed towards a social environment among lower strata characterized by a combination of stigmatization and distrust of medical services, which is very unconducive to retention in care.

Tracking the origin, early spread, and ignition of pandemic #HIV-1 through new approaches to phylogenetic analysis

17 Nov, 14 | by Leslie Goode, Blogmaster

“Distribution of HIV-1 subtypes in a population”, state Mumtaz & Raddad (STI) in a study of the HIV pandemic in the Middle East, “tracks the spread and evolution of the epidemic”.  Various studies covered in our previous blogs have attempted to read the history of the progress of the HIV epidemic through the evidence of the distribution of HIV genetic sub-types: Tatem & Salemi (STI/blogs) have investigated its spread throughout Africa; Zhao & Roca (STI/blogs) pass beyond the human epidemic to consider the genetic evidence for repeated transmission from chimpanzees to humans.

Now Faria & Lemey (F&L), in a paper recently appearing in Science, offer an account of the critical early phase of limited spread within Central Africa and the ignition of pandemic HIV-1 around 1960, bringing statistical approaches to bear to HIV-1 sequence data.  F&L produce a time-scaled phylogenetic “tree” of HIV-1 group M lineages, matching these up in each case with the geographical location of their earliest manifestation.

This approach points to the very strong likelihood (PP = 0.99) of an origin of the HIV1 epidemic in Kinshasa around 1920. Study of lineage migration shows comparatively early spread from Kinshasa to Brazzaville (Republic of Congo (RC)), and Mbuji-Mayi and Lubumbashi (southern Democratic Republic of Congo (DRC)) along the railway network, and its arrival around a decade later in Bwamanda and Kisangani (northern DRC).  The crucial period around 1960 (1952-1968) sees, for group M HIV-1, an exponential growth in levels of M-group transmission, while growth in group O transmission remains at previous levels.

But the most interesting aspect of the study relates to conditions around the sudden surge in group M HIV-1 transmission, as indicated by the accelerated ramification of viral lineages during the crucial period.  The authors consider the hypothesis that associates this ramification with the geographic dispersal of the epidemic, with the lineages emerging in the more widely distributed populations now being infected.  They reject this hypothesis, however, on the grounds that, when the epidemic history of lineages maintaining ancestry within Kinshasa is constructed, these turn out to exhibit phylo-genetic characteristics that are comparable to those of lineages in central Africa.

They conclude that the crucial explosion of pandemic HIV-1 transmission probably occurred in Kinshasa as a result of a historic contingency affecting a particular population subgroup.  Prime contenders are iatrogenic transmission as a result of the administration of unsterilized injections at STI clinics, and/or post-independence changes in sexual behaviour e.g. among commercial sex-workers.  The authors find support for the iatrogenic hypothesis in a study of the hepatitis C virus in the DRC which shows that it exhibits an age cohort effect, and in reports of an epidemic of hepatitis B in Kinshasa around 1951-2.

“Hispanic” label masks the specificity of the Puerto Rican #HIV problem in US Northeast

12 Nov, 14 | by Leslie Goode, Blogmaster

Interventions for HIV prevention should be informed by an understanding of the long-term source of infection, and not just by recent distribution (Mishra & Boily (STIs)).  Amongst recent studies that have sought to inform future interventions are investigations of known subgroups thought to be a potential bridge into the wider population – such as migrant workers, or sex workers (STI/Kissinger & Shedlin; STI/Faisel & Cleland).  There are other investigations that seek to refine on the definition of such groups (STIs/Davies & Tucker; STIs/Bayer & Coates).  But could there be instances where classifications established for the purposes of data collection actually mask the existence of the groups that could have epidemiological importance?

Puerto Ricans in the north-east of the US may be an interesting case in point.  A recent article (Deren & Santiago-Negron(D&S)) claims that the classification “Hispanic”, generally applied to Puerto Ricans for the purpose of data collection, may have obfuscated the distinctiveness of a Puerto Rican subgroup with its own specific risk profile, and considerable unmet medical health needs.   As though to illustrate the point, D&S assemble various data relating to strong correlations, for example: between AIDS diagnosis and being Hispanic; between residence in the North East of the US and IDU-associated HIV; between HIV incidence and being a Hispanic IDU.  Cumulatively – and taken along with the concentration of Puerto Ricans in the NE, and what is known of the high incidence of IDU-associated HIV in Puerto Rico itself – these data indicate the probability of a strong association, at least for the US North Eastern states, between Puerto Rican Hispanic identity and a high risk of drug-derived or heterosexually-transmitted HIV.  Furthermore, it is not only the subgroup of US Porto Ricans that have tended to slip under the net, according to D & J; high levels of IDU-transmitted HIV in the island of Puerto Rico itself have failed to attract due attention, on account of the peculiar status of Puerto Rico – which is a US territory, without being a US state.  As a result, Puerto Rico tends to figure neither in statistics for the Caribbean (as a US territory), nor in statistics for the US (since it is not a US state).

For Puerto Ricans – with an AIDS fatality at six times the US average and rates of new IDU and heterosexual infection twice that of the US – the problems of their anomalous status do not end with inadequate reporting.   Budgets for syringe exchange programs (SEPs) are only a fifth of what they are in the US Northeast, while Puerto Rican IDUs are only a fifth as likely to be in treatment.  SEP schemes cannot be funded by the US federal government, while the local Puerto Rican response to the drugs problem has, until recently, been largely provided through faith-based programs, with addiction defined by the Mental Health Law (2000) as a spiritual and social problem rather than a mental disorder.  Relocation to the US Northeast for drug treatment has become a commonly recommended option, with 85% of Puerto Rican admission to drug treatment taking place in the US Northeast.

In view of all this, D&S recommend partnership between federal, local and private entities to develop a cross-regional approach to the Puerto-Rican epidemic.  They also point out the challenges posed for such an approach by the unique status of Puerto Rico as a territory, without the full representation available to states in the Northeast.

“Fast-tracking” the end of the HIV epidemic

8 Oct, 14 | by Leslie Goode, Blogmaster

At a high-level event on the margin of the UN General Assembly meeting in New York last month, convened with the support of UNAIDS, world leaders agreed that ending the AIDS epidemic as a global threat by 2030 was possible, and should be placed at the centre of health development goals.  The brochure, Fast Track (7 pages), sets out the agreed proposals.  The context of the agreement is the General Assembly’s discussion of 17 Sustainable Development Goals for 2015-2030 to replace the Millenium Development Goals that are due to expire in 2015 – and, more specifically, the formulation of targets to accompany the Sustainable Development Goal for health: “To ensure health lives and promote well-being for all at all ages”.  The week before the UN General Assembly saw the early online publication of a paper by 16 international experts (Norheim & Peto)  proposing as a “feasible goal” the overall reduction of pre-mature deaths by 40% – including, as an important element, a reduction by two-thirds of deaths due to HIV.

The proposals contained in Fast Track are in line with the most radical response scenario set out in pp.291-3 of the UNAIDS GAP report (July 2014), involving reduction of new adult infections to 500,000 by 2020, and 200,000 by 2030.  Also reminiscent of the earlier document is the sense of the tide of the epidemic having turned, and of its increasing concentration within the cities of 30 or so nations – and, more specifically, within fairly specific populations of those cities, such as sex workers, intravenous drug-users, etc..  This concentration represents both a challenge and an opportunity (STI/blogs/UNAIDS GAP report).  The new element in Fast Track is a three-fold target of 90%: for the proportion of those infected should know their HIV status, the proportion of those knowing their HIV status who receive anti-retroviral therapy, and the proportion of those on therapy who achieve undetectable levels of viral load – all by 2030.  A glance back at the GAP report itself reveals what a challenge this is likely to be (e.g. at present, 3 in 5 of HIV infected not receiving ART).

Also timed to coincide with the proposals (25th September) was the announcement of a scheme to expand access to viral load testing through an agreement affecting the pharmaceutical Roche’s COBAS® AmpliPrep/COBAS TaqMan HIV-1 Test version 2.0 (see STI/Hatzakis & Kantzanou).  Access to viral load testing is essential to monitoring of HIV-infected people (STI/Hill & Minton), and its high cost has been an obstacle to progress in low and middle income companies up until now.  The new agreement may smooth the way to the achievement of the ambitious targets set out in Fast Track.

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