USA - Treatment as Prevention

posted: 10/12/2009

The USA has joined the list of countries producing national statements about how effective HIV treatment can make passing on HIV during sex very unlikely. 

The USA statement uses much the same evidence as the earlier Swiss, French and German statements on HIV treatment as prevention that we have reported. However, it is a lot more cautious, urging continued consistent condom use.

"In summary, for couples in which one member is HIV-infected, treatment of the infected partner with effective ART and suppression of viral load to undetectable levels should greatly reduce the risk of transmission to the uninfected partner. However, this risk is not eliminated and it may not be maximally reduced at all times due to some of the factors discussed above. Moreover, the likelihood of transmission may be expected to increase with repeated exposures over time."

"In a model which estimated transmission risk in the setting of suppressed viral load (<50 copies/mL) without intercurrent STIs, the number of expected transmission events occurring within a population of 10,000 serodiscordant couples over 10 years was estimated to be 215 for female-to-male transmission, 425 for male-to-female transmission, and 3,524 for male-to male transmissions [31]."

"In a meta-analysis of data from 11 cohorts including 5,021 heterosexual couples observed no transmissions among persons receiving ART with a viral load of <400 copies/mL; however, analysis of the data was compatible with the possibility of one event per 70 person-years [32]. For this reason, it is important that individual couples recognize the risk, and use additional preventive methods (e.g., condoms) in order to further minimize the chance of transmission."

So they advise condoms for heterosexual couples to prevent a 1 in 70 person years possibility of transmission.

This statement and advice comes from the US Centers for Disease Control.

Effective HIV treatment where the viral load is undetectable reduces the risk of HIV transmission but some slight risk remains. The risk is higher for gay men than most heterosexual people, and sexually transmitted infections especially raise the risk of transmission.

US Centers for Disease Control statement Effect of Antiretroviral Therapy on Risk of Sexual Transmission of HIV Infection and Superinfection [read on webpage] OR download it as a pdf

French statement

German statement

Swiss statement

Children’s HIV Mental Support

posted: 27/11/2009

Ways to meet children’s mental health support needs before, during, and after a parent (or other close relative) dies with HIV, are given in a new international review from aidsmap / NAM.

It's written for resource-limited settings, but the how-to advice is excellent for children here and everywhere. Most useful in the UK are sections on ‘addressing grief and bereavement,’ checking for childhood mental health problems, and basic and more advanced ways to support children affected by HIV-related deaths.

A useful overview to helping children cope with death and grief the review recommends is the recently published guide Children’s Palliative Care in Africa, (download the whole book free - the only price to pay is taking part in a quick survey). 

One chapter in this book provides advice about

• making memory boxes (to collect items that remind them of the person who has died and times they shared)
• making a family record to help a child or young person gain a sense of where they and the person who has died fits into the family. This is particularly important when a child is to be removed from their old home, or separated from siblings or cousins, and hence when there is a danger of losing a sense of his or her ‘roots’
• telling the story by helping the child write or tell (with an adult writing) their story so that they remember clearly what happened — which can provide carers an ideal opportunity to pick up misconceptions and misunderstandings
• handprints: a print of their hand and their parents and other loved one’s touching
• writing a “children’s will”: children are sure to have some items that they treasure and they might have a clear idea of what they wish to happen to these
• permanency planning so that children have a clear idea about what will happen to them (if they are bereaved)
• a “bereavement tree” (a practical tool that sensitises people to the feelings and behaviours of individuals and expectations of society, to create awareness about bereavement in order to encourage community support to all bereaved people — there is an appendix with this tool in the book.

The book also highlights the importance of spiritual development (as well as play), and describes a number of beliefs and practices surrounding death in Africa.

Another fine resource

Some other useful resources can be found in the April 2009 issue of Together Now, the newsletter of the International HIV/AIDS Alliance in India, including using art therapy for children and child-centred counselling. The article also usefully describes different mental health screening tools for children.
 

Children’s Palliative Care in Africa

download the whole book free here

The international review After my parents died: The effect of HIV on the mental health of children: a clinical review

HIV and Hepatitis B or C

posted: 27/04/2009

BHIVA has written new guidelines for the management of co-infection with HIV and hepatitis B or C  and want people's comments. These guidelines replace the existing separate guidelines for HIV and Hepatitis B, and HIV and Hepatitis C. You can make your comments at the BHIVA website


These 2009 guidelines incorporate all new relevant information since the previous versions in 2005.

For 2009 we have decided to amalgamate the two guides for hepatitis coinfection into a single document. This avoids duplication, because general treatment for chronic liver disease is similar for both.

The translation of study data into clinical practice is often difficult, even with the best possible evidence, because of differences in factors such as trial design and inclusion criteria. Recommendations based upon expert opinion have the weakest evidence but provide an important reason for writing the guidelines – to produce a consensual opinion about current practice. The Writing Group seeks to provide guidelines that optimize treatment and management, but this needs to be tailored to fit the person - the draft is not suggesting a fixed standard for all.

Changes
The major changes/amendments include:

• More discussion on hepatitis screening and prevention;
• Clarification on the role of liver biopsy and non-invasive liver fibrosis assessment;
• More emphasis on screening for delta virus;
• More discussion on end-stage liver disease management and HCC screening;
• Molecular diagnostic tests used for the diagnosis and management of Hepatitis B and Hepatitis C;
• Revised CD4-based guidance on the management of chronic Hepatitis B;
• Management of acute Hepatitis B;
• Revised guidance on the management of chronic HCV, including ART interactions;
• Management of acute Hepatitis C
• Management of treatment non-responders and relapsers in both chronic Hepatitis B and C.

The consultation deadline is 5 June

BHIVA consultation page

Managing Coinfection with HIV and Hep B and C download the pdf

Online feedback form