First Viral Load Predicts

posted: 10/06/2010

The first viral load is a good predictor of how HIV may develop in each person, British researchers have found. That makes regular check-ups at a specialist HIV clinic important, especially if the person’s first viral load was above 10,000.
 

At each HIV clinic visit people have blood tests. Two of the most important are those which monitor the CD4 cell count and Viral Load .

The CD4 cell count gives a rough picture of the health of the immune system. The higher it is, the healthier the immune system.
 

Viral load measures how much HIV is circulating in the blood. Low Viral Loads are best – ideally when they can’t find any HIV in the bloodstream, because it is ‘undetectable’.
 

New UK research from London’s Royal Free Hospital has underlined that it is important to check both CD4 count and Viral Load regularly. Usually HIV clinics do this 3 or 4 times a year, sometimes more often.
 

Close relationship between Viral Load and CD4

The new study shows that there is a very close relationship between the viral load going up and the CD4 cell count falling. Exactly how this works hasn’t been clear to doctors and the investigators wanted to find out more.
 

First ever Viral Load - 'Baseline' - is good predictor

So they studied 1169 people for around 10 years. On average, CD4 cell counts fell by 66 each year. But the higher a person’s first ever viral load (often called the ‘baseline viral load’), the faster the person lost CD4 cells. And the more viral load increased from the ‘baseline’, the faster a person’s CD4 cell count fell.
 

10,000 or more

A person with HIV becomes vulnerable to potentially life-threatening illnesses when the CD4 cell count falls to around 200. The research showed that 96% of patients whose CD4 cell count fell to 200 had had a ‘baseline’ viral load above 10,000. And 86% of people whose CD4 count fell dangerously low, to around 50, started with their first viral load, the ‘baseline’ at 50,000 or so.
The researchers also found that falls in CD4 cell count predict increases in viral load.
 

“We show here that variability in CD4 cell count decline is linked more closely to viral replication than has previously been documented,” conclude the researchers.
 

Results help decide when to start treatment
This information may help people and their doctors decide when to start HIV treatment. If the first ever Viral Load, the 'baseline' was 10,000 or above, it makes even more sense to go for regular check-ups at the HIV clinic and to think seriously about starting treatment at a CD4 count of 350. Treatment should work better if it starts at 350, than if the CD4 count is allowed to fall below 350, before HIV treatment is started.

For more information on tests used to monitor health with HIV, you may find NAM’s booklet CD4, viral load and other tests helpful.
 

Source with reference

Clinics Guide to Law and HIV

posted: 23/04/2010

Have your say about the draft guidance for HIV clinics from BHIVA / BASHH about HIV transmission, the law and the work of the clinical team, 2010. The deadline for your comments is Friday 21 May 2010.

There have been prosecutions for reckless transmission of HIV in the UK since 2001 (Scotland) and 2003 (England & Wales). The prospect of prosecutions raises complex questions among medical practitioners about their ethical and legal responsibilities related to HIV transmission, particularly around disclosure of information on HIV status.
 

Although established generic ethical and professional principles continue to apply, certain features of the HIV epidemic have required special consideration.
 

An underlying principle in the provision of clinical care for people with HIV is the need for a secure and confidential environment in which extremely sensitive matters can be frankly and fully discussed. The importance of ensuring that full trust is maintained by people with HIV in their clinical services is fundamental, not only for the health of people living with HIV but also for people who may wish to seek information or testing and thus for the wider public health.
 

This guidance document sets out these responsibilities, and how these relate to the roles and responsibilities of health care professionals when caring for individuals infected with HIV.
 

Roles and responsibilities of Health Care Professionals

• Health care professionals have a central role to advise and support patients and to maintain confidentiality according to professional guidance and the law.
• For HIV positive individuals, advice must include the routes of HIV transmission, how to prevent transmission, with information about safer sexual practices and the use of condoms.
• Discussion of sexual health needs must take place regularly according to relevant BASHH guidelines to enable the giving of appropriate advice.
• There is individual and public interest in maintaining confidentiality; this may be outweighed in order to prevent serious harm to others.
• It is important when considering breaching confidentiality to weigh up all potential harms as there may be situations where disclosure of HIV status to protect a sexual partner results in considerable harm to an individual e.g. domestic violence.
• In situations where a health care professional believes that an HIV positive individual continues to put close contacts at risk their duties and subsequent action depend upon the type of contact (see figure one).
• No information should be released to the police unless there is verified consent from the patient or there is a court order in place.
• It is up to an individual patient to make a decision about complaining to the police and health care workers should remain impartial during discussions with patients.
• Those involved (complainant and defendant) in cases of reckless transmission are likely to need specialist legal advice and support and referral to THT direct would be appropriate.
• Sources of further information are listed in appendix two.

Vulnerable Groups

There are special considerations with regards cases of alleged reckless transmission in those under 18, or anyone with learning difficulties, discussed in section 5.
 

You can download the document and then submit any comments using this online form. 
 

Please make your comments here by Friday 21 May

Sustaining African Community Leadership

posted: 14/01/2010

Sustaining Community Leadership is the theme of the latest issue of the African HIV Policy Network’s Newsletter. It has pieces on

• surviving the economic downturn
• the importance of Africans and others making their voice heard by voting in the general and local elections (which will almost certainly be on May 6th)
• HIV positive people being leaders and making a community impact
• Africans disappearing from HIV clinics (by Chris Morley, George House Trust’s policy expert)
• Resources and working to improve Faith responses to HIV, (they have more information on their website)
• HIV and the workplace – meeting the needs of staff with HIV
• Their media toolkit for working with journalists – details and download it from their website
• Young people using the web and mobile phones for HIV messages
• Fighting HIV stigma
• Using SHoutloud to have your say about your local HIV and sexual health services.

This Sustaining Community Leadership issue

 Past issues of AHPN's newsletters

Lost to Care

posted: 25/11/2009

People diagnosed with HIV who drop out of HIV clinics was first highlighted as national issue by George House Trust in Insight this year. Now people lost to clinics and care is covered in more detail in an excellent leading article in the latest issue of NAM's HIV Treatment Update.

'Lost to Care - the mystery of the disappearing patients' by George House Trust policy expert Chris Morley and editor of HIV Treatment Update Gus Cairns, tells why up to 1 in 3 people disappear from HIV care at some stage after diagnosis, whether this puts people’s lives in danger, and it offers some suggestions for how to deal with clinic drop out.

Stigma too
The same issue has an article on HIV stigma – Punching Fog. It tells how people with HIV telling their own stigma experiences through the UK section of the global website HIV Stigma Index is helping the stigma fight-back.

HIV Treatment Update

People living with HIV can get HIV Treatment Update free, others have to subscribe and pay; this issue (November 2009) will be published in a few months in the online archive, also on that webpage.

Clinics Contact Tracing Recent HIV Works

posted: 08/07/2009

Contact tracing people with acute (very recent) HIV infection leads to diagnosing others with HIV, such as newly infected partners, say investigators from North Carolina, USA, in the online edition of the Journal of Acquired Immune Deficiency Syndrome.

Contact tracing of people with acute, or new, HIV finds more people with HIV who are undiagnosed than tracing the contacts of people who have had HIV for a while - what medics call chronic HIV infection.

1 in 4 partners of newly infected people were also newly infected

A quarter of the partners of people with acute HIV infection contacted were also found to have acute infection.

“Identifying persons with acute HIV infection is vital to controlling the spread of HIV. Phylogenetic and epidemiological analyses among other populations have demonstrated the crucial role this group plays in forward transmission,” comment the investigators.

How they did the study

In 2002, the North Carolina Department of Public Health began using nucleic acid amplification testing (NAT) to identify individuals with acute HIV infection. The theory they wanted to test was that people with new (acute) HIV infection would be able to identify more of their sex / drug using partners than people infected longer ago.

To test this idea, they compared the number of partners found by contact-tracing services for both people with new and older HIV infections. The period of the study was 2002 to 2007.

Contact details collected next day

People with acute HIV infection were interviewed by trained counsellors within a day of their diagnosis, whereas those with established HIV infection were seen within an average of a week of diagnosis. People with new infection were asked to name their sexual partners for the past six months, and those with established HIV were asked to name partners for the whole year before.

They compared the results from 120 people with a new HIV infection and 9044 people who had HIV for some time.

What they found

People with new HIV reported a median of two partners in the six months before interview, whereas those with established infection reported a median of one partner. About half of the named partners who were contacted had previously taken a HIV test. A quarter of the contacted partners already knew they were HIV-positive.

They found that the partners of people with new HIV infection were more likely to be tested than the partners of patients with established infection. There wasn't much difference in the proportions of partners becoming newly diagnosed after contact tracing, between men with new HIV themselves and men with longer term HIV infection (twelve of 264 [5%] vs 468 of 7899 [6%]).

However, of these newly-diagnosed partners with acute infection, 25% were also found to have acute infection, compared to below 1% of partners of individuals with established infection. If you want to find people with acute HIV infection, testing the partners of the newly infected makes sense. People with new (acute) HIV infection are far, far more infectious than people infected a few months or years before.

Twice the names remembered with acute HIV

Statistical analysis showed that people with acute HIV named over twice as many total named partners as did those with chronic HIV infection.

Moreover, 9% of the partners of individuals recently infected with HIV were themselves HIV-positive compared to 5% of the partners of patients who had HIV infection for a year of more. This difference was significant (p = 0.03).

The investigators calculated that acutely infected individuals identified 1.93 times as many newly diagnosed partners than did individuals with established HIV infection.

“This is the first population-based study to demonstrate that persons with acute HIV infection identify higher numbers of named partners per index case than persons with established infections,” write the investigators. They add, “persons with acute HIV infection also have a higher proportion of partners who get tested for HIV.”

Urgent contact tracing of people with new HIV works well

“The results of this analysis”, conclude the authors, “lend additional support for routine identification of acute HIV infections as a means to increase the number of partners reached by [contact tracing] and the number of new infections identified.”

Reference
Moore ZS et al. Number of named partners and number of partners newly diagnosed with HIV infection identified by persons with acute versus established HIV infection. J Acquire Immune Defic Syndr (online edition), 2009.

Source