HIV tests can now be done at home

People will now be able to test for the disease at home

Digital sexual and reproductive health social enterprise, SH:24 has announced that it will be offering free HIV self-tests that can be done at home.

SH:24 has produced over 200,000 STI self-test kits since 2015 and has won awards for its service.

Now, SH:24 is providing free HIV testing to better understand what influences an individual when choosing a testing kit.

There are currently two types of self-test kits for HIV, one involves taking a prick of blood from a finger and will provide results in 15 minutes. The other involves the individual providing 15 drops of blood in a tiny pot and returning it to the lab.

Those who take the test will be asked to fill out a short survey, the data from which will be used to inform future HIV prevention research and service development at SH:24.

Individuals who choose to take the self-test at home will receive their results via text or over the phone by one of SH:24’s trained clinicians. Where necessary, patients will be referred for further treatment.

Everyone who takes the home test will receive a follow up call from an SH:24 employee offering advice.

Alongside the test, SH:24 offers 24 hour support for individuals.

HIV treatment has improved dramatically during recent years with huge strides being made in testing and treatment. According to Public Health England in 2016 new HIV diagnoses decreased, despite the same levels of testing. Home testing has helped with this progress.

HIV Prevention: Bridging The Gap Between Research And Impact

We are at an incredible moment in the history of the HIV/AIDS response, which reflected in the vibrancy of the HIV Research for Prevention (HIVR4P 2018) – the only global scientific conference focused on the fast-growing field of biomedical HIV prevention research. Today, the latest research in different areas of biomedical HIV prevention, including vaccines, rings, microbicides and other female-controlled forms of prevention, pre-exposure prophylaxis (PrEP) and long-acting delivery systems, offer the greatest promise of significantly slowing the toll of the disease.

And yet we are far away from ending the AIDS epidemic by 2030, and are also falling short of achieving the 90-90-90 UNAIDS targets by 2020.

While there has been immense progress in the field of HIV science, we are yet to see its public health impact on the ground.

“It is not just about R&D but about R&D and D – research and development, and delivery. If you take any one of those three letters out, we fail. Each of them is equally important. Undoubtedly, it is difficult to successfully complete the clinical study for a new product, but delivering that product to the people for whom it was designed, is harder.

Whether it is the ARVs, PrEP, vaginal rings, multipurpose prevention tools like the female condom, we see a huge gap in delivery”, said Mitchell Warren, Executive Director of AVAC, in an exclusive interview given to CNS onsite at the HIVR4P Conference being held in Madrid.

EVERY NEW INFECTION OF HIV COULD HAVE BEEN AVERTED:

Till to date, more than 35 million people have died of HIV-related illnesses, and another 37 million people are living with HIV worldwide. In 2017 alone there were 1.8 million new infections (87,580 in India) and 940,000 deaths (69,110 in India). Governments have promised to end AIDS by 2030.

But the new cases graph is not dipping towards that steeply enough. Why are we failing to prevent new HIV transmissions?

According to Mitchell, “We are failing for a number of reasons. One is our failure to translate science into programmes fast enough. The second is the fundamental failure of the system in which people who need prevention and treatment most are least likely to be able to access it. To bridge this wide access gap we need to do two things simultaneously. We clearly need additional prevention options.

But more importantly, we need to simultaneously focus on our (delivery) systems. Countries need to build prevention programmes that respect people’s choices and needs and are capable to deliver any new prevention method. If there is anything we need to do differently, it is that we need to listen to the people who are in need of the product(s).

We have to act upon what people want, when they want and how they want it. We have to listen to them in their diversity and respect their different choices. One size will never fit all. A successful HIV/AIDS response is the one that takes in all the imperfect things we have and bundles them together in the most perfect programme.”

PROMOTING FEMALE-INITIATED PREVENTION METHODS:

Women seem to be shortchanged as far as their own sexual and reproductive health is concerned. This is true not just in HIV prevention but for many other public health issues as well. Mitchell laments that even though sexuality is a part of human nature, people are scared to talk about sex. They are not comfortable about letting women make choices about what they want to put in their vagina.

“We want young women to have choices. But more often than not (we know this from reproductive health programmes) those choices are made by governments, by health providers and by their male partners— whether they can use an injectable contraceptive or the pill or an implant. Despite having so many wonderful family planning options, women cannot choose the one they want.

Many times their public health programme offers them just one or two choices because those who dictate their choices are often men. So, patriarchy, coupled with moralizing conservative governments, creates a complex ecosystem. But we need to inform people better, rather than moralise.

We need to talk about the female initiated prevention options and let the product user decide for herself. In fact, all adults, irrespective of their age or sex, should be free to make informed choices about which product to use for the benefit of their own health and not be influenced by their partners, peers, parents or by the moralising politicians, health providers and clinicians”, he says.

NEW TREATMENT AND PREVENTION OPTIONS SHOULD NOT MAKE US COMPLACENT:

People know that HIV is no longer a death sentence, that they can get a pill everyday and live healthy and long, and not infect others once they have undetectable viral load. This is an empowering and important message. But if not communicated properly, it could have unintended consequences of making individuals and governments complacent that getting HIV is no big deal. Let us not forget that HIV still is a big deal. It is an epidemic.

Even though we can treat it, but the more people are infected, the harder it would be to treat them all from a financial perspective. We have to stop new infections. So we got to find the right balance to not scare people, not stigmatise PLHIV, but at the same time make them realise that being HIV free is possible and is important.

Mitchell’s sane advice is to be laser sharp in our focus – not only around new technologies, but also upon the programmes and infrastructure that can deliver a whole range of products. We need to do both— technology development and building systems that address the fundamental structural barriers—in a comprehensive, integrated and sustained way.

If we do one and not the other, we cannot end the AIDS epidemic. We have to create a demand for all the available effective prevention tools and make all of them available to people so that they can choose what suits their needs best. But all this has to be in an ecosystem where one can talk about sex and about prevention of HIV in a human rights based comfortable way.

Documentary ‘Lovesick’ revolves around love story of HIV couples

Documentary 'Lovesick' revolves around love story of HIV couples

Two US-based filmmakers, Ann S. Kim and Priya Giri Desai, have made a documentary titled “Lovesick” which revolves around the love story of an HIV positive couple. As the documentary had its India premiere at the 20th Jio MAMI Mumbai Film Festival, the makers said they wanted to explore the universal condition of all HIV patients through an Indian story.

The story of “Lovesick” revolves around the journey of Suniti Solomon, a doctor who started working with HIV-affected sex workers and slowly realised how people from different walks of life who are suffering from the disease live a miserable life of a loner as they cannot get married due to their condition.

Therefore, the Chennai-based doctor decided to start a matchmaking service for AIDS patients so that at least they can live happily with a life partner.

On what intrigued them to make the film, Kim told IANS here: “Two very important elements for a documentary film is character and access to the story. Dr Suniti Solomon has a wonderful personality and she was very open to life. So when we got to know the story, we wanted to explore the world of HIV Positive patients differently.”

“Yes, we intended to discover that world but we looked for something very universal that will not only be limited to Indian audience but globally, with its relatability,” added Desai.

The filmmakers shot Solomon’s journey for eight years and found her story from her son, who is Desai’s friend.

Set in southern India, the documentary’s narration juxtaposes the traditional rules of arranged marriage that focuses on social status and astrology, different from what Solomon believed is important — medical history to be sure that none of the potential bride and groom is HIV positive.

Was that a conscious decision?

Kim said: “When we were waiting to interact with some HIV positive patients, we were just observing people and having a quick chat with them. We were trying to explore their idea and thought on marriage — why is it so important for an Indian society to get married and what are the rules that they follow, because back in the US, we go little easy on these rules.”

“When we asked a few question on marriage to a majority of orthodox people, those are the natural reactions we have got,” she added.

The story ends as a love story between two AIDS patients — Manu and Kathik, courtesy Solomon who was instrumental in their match-making.

Whether they believe in them or not, the fact is Manu and Karthik felt the pressure of following those rules.

“Though it was not our agenda to take the reference of those 12 rules and position them opposite the viewpoint of Dr Solomon, we attempted to utilise these elements to structure our narration.”

“You know handling HIV positive is no big deal, handling the social stigma that is attached with it is difficult for patients”, said Desai, who was born in a South Indian Brahmin family but brought up in California.

The film has been nominated under the ‘Discovering India’ category at the MAMI Mumbai Film Festival, and it is the only documentary film in the nominees, which include feature films like “Rajma Chawal”, “Chippa” and “Namdev Bhau”.

Filming the heart-warming documentary was a sweet-bitter experience for the director duo, Desai made an interesting point about their on-field experience.

“In Chennai, when I was interacting with the locals, they would not open up easily, maybe because I am an Indian coming from the US. But whenever Kim was talking, since she is a foreigner, people would voluntarily talk about our culture without any hesitation. I would say her presence in our crew worked in our favour to set the story close to reality,” shared Desai.

Kim is a Korean brought up in the US. Asked if she discovered anything new about India during the filming of “Lovesick”, Kim said: “After my college, I actually came to India and travelled mostly in the northern side. This time when we were filming, I explored the southern part.

“Maybe I liked south Indian food a little more than north Indian food, which is spicy,” she quipped.

While Kim did not find India very exotic and unfamiliar, she said: “There is a certain similarity we find in the Asian society. Our family and social cultures are somewhere similar and that is why I did not feel out of place.”

Why Does Only One Type of HIV Cause Almost All Infections in India?

Why Does Only One Type of HIV Cause Almost All Infections in India?

The reason HIV-1C is the most common cause of the estimated 2.1 million HIV infections reported in India and half of all global infections is being unraveled. Scientists found that it stays on its relentless march by making two copies of an important region of a protein, according to a study published in the Journal of Biological Chemistry.

“Our work examines one unique molecular trick HIV-1C appears to use towards replication fitness,” says Udaykumar Ranga, lead author and a professor at HIV-AIDS Laboratory, Molecular Biology and Genetics Unit, Jawaharlal Nehru Centre for Advanced Scientific Research, Bengaluru.

“HIV-1C can efficiently duplicate certain regions of its genome to gain replication advantages unlike all other genetic families of HIV-1.”

Its M.O., mojo and moxie

HIV – the human immunodeficiency virus – is so versatile that researchers working with it cannot but marvel at its stealth. As Ranga explains effusively, it demonstrates many unique properties that no other pathogenic organism – viruses, yeast, fungi, protozoa or bacteria – can.

Off the blocks, HIV is highly proliferative. Every single unit churns out 10-100 billion new daughter viral particles every day. Even if 99% of these new viral particles are defective, what is left is still an enormous infectious population of HIV (1% = 100 million to 1 billion).

What’s more, Ranga says, “the virus does not pay for this extraordinary rate of proliferation.”

Secondly, it can also spawn unprecedented levels of genetic variation. HIV intentionally introduces errors into its daughter virions (viral particles) to make them all different from one another, which may make a large proportion of the new viruses defective. But this helps fight off threats from the immune system of a new recipient or a new drug discovered only a week ago, or even a drug yet to be discovered.

“The viral population is huge and diverse to counter any adverse condition, with a subpopulation readily having a survival advantage,” Ranga explains.

To top it off, it sits and hides, and lurks in the chromosomes in the nucleus – called chromatin – unseen by and inaccessible to the immune system, vaccines and drugs. No other pathogen is known to use this molecular strategy.

“The immune system is not designed to find a virus hiding in the chromatin,” according to Ranga. “There are many additional strategies HIV employs towards replication fitness.”

The HIV-1 families

HIV-1 is not one. It’s a hive. Its genetic variation is humungous. It works with intention, seemingly endowed with a mind of its own.

As Ranga puts it, sort of “like the Indian caste system – a caste to sub-caste to sub-sub-castes and on and on.” HIV-1 has many genetic families, approximately nine primary families (A through K) and a large number of recombinant forms. Each of these families can be divided into sub-families and sub-sub-families.

Of these genetic families, the one denoted ‘subtype C’ is the most important one because it causes half of all the infections in the world. Nearly all of the HIV infections of India are due to HIV-1C, and genetic families such as  A, B, D, E and others are not in India. In the West, family B dominates.

The viral family of subtype C dominates India, China, and Africa. It is also so variegated that the Indian HIV-1C strains may differ from the South African HIV-1C strains at the phylogenetic level. It shows its extraordinary capacity to adapt to the available environmental conditions, and Ranga reckons there must be a molecular basis underlying this success, known as replication fitness.

“It will be technically difficult, even impossible, to ascertain a single reason underlying the epidemiological success because many independent factors may contribute towards a specific characteristic simultaneously, each factor making a partial contribution to the gross total. The intrinsic molecular qualities, a founder effect (‘the first arrived’ has an advantage), the host factor landscape and the like all could make a difference,” Ranga says.

His lab examines the first factor: the intrinsic molecular properties of HIV-1C. Despite all the geographical variations, “all the HIV-1C viral strains appear to bring about an important change in the Gag protein to gain a major proliferative advantage.”

Clueing in on the PTAP motif

When Ranga and his team began nearly 15 years ago, he says he was surprised to see new viral variants emerging only or mostly in the HIV-1C family. Among other things, the lab focused on the causes underlying the dominance of subtype C, specifically if subtype C viruses isolated from HIV patients in India have molecular features that differ from other subtypes found in India or other countries.

As Prabhu Arunachalam, one of the study’s co-authors and now a postdoc in the US, narrates, they screened 56 HIV-infected people from India who were not being medicated.

When they sequenced the viruses thus obtained, the majority of the patients seemed to be harbouring ones with genomes of an expected length. However, eight people had viruses that had a small region called the ‘PTAP motif’ duplicated.

A motif, Arunachalam explains, is a small stretch of DNA sequence that is characteristic of a certain biological function.

For instance, PTAP – i.e. the amino acid sequence proline-threonine-alanine-proline, in that order – motif helps in the budding of viruses from cells. This motif is present in HIV-1 as well as several other retroviruses. But the function of this motif in all the viruses is the same: to help viral budding.

“The PTAP motif achieves this by recruiting proteins that transport the virus out of a cell,” Arunachalam says. In this way, the virus uses cell-sorting machinery to jump out of the cell and infect new cells.

To determine the range of viral budding, they first analysed the samples with a lower power technique (Sanger sequencing) and next with next-generation sequencing. The latter costs more money and so it was not done on all 56 samples in the beginning.

The analysis showed that the new variant viral strains containing duplication – i.e. double-PTAP viral strains – dominated the original single PTAP viral strains. About 70-99% of the viral strains in the blood were double PTAP-strains in almost all the subjects, at multiple follow-up times up to 30 months.

“This proved that HIV containing two PTAP domains has a great replicative advantage over the strains containing only one domain,” says Ranga.

According to Arunachalam, the finding suggests two important things. One: Viruses are evolving in patients who are not on medicines. Two: Once a virus duplicates this motif, it becomes the fittest and takes over within a period of six months (in the study, this was the time period after which each sample was taken).

Ranga thinks the dominant viral strain – the double-PTAP viral strain – is more likely to be transmitted to new people. He adds a caveat that they cannot say for sure because “survival advantage in individual subjects need not necessarily translate to spreading advantage in a population because additional selection forces operate in the population which are absent in individuals.”

“Nevertheless, the chances of replication advantage are expected to be higher at the population level if this is the case at the subject level.”

They also constructed molecular clones of the virus in the laboratory to see if the domination of the double-PTAP strains could be recreated in laboratory conditions.

“In a competition between the two viral strains under the laboratory conditions, the domination of double-PTAP viral strain was reproducible,” says Ranga. That suggests these strains may spread in the population in large numbers in the coming years.

These new variants arise from existing natural viruses through sequence duplication, he adds. But once they are made, they completely take over the job of destroying the immune system from the natural virus.

“This work, for the first time, showed that the length of sequence duplicated is greater than for the other dominant clade, clade B,” said Vinayaka R. Prasad, a professor at the department of microbiology and immunology, Albert Einstein College of Medicine, New York. He was not involved in the study.

The study also provides, for the first time, a mechanistic explanation for why PTAP duplications matter. They enable the virus to better egress from infected cells, according to Prasad.

“This paper makes a solid new contribution to our understanding of the evolution of HIV-1 C, which appears to be constantly undergoing changes and is setting itself as being very different from all other HIV-1 clades,” he added. “This may make the control of HIV-1C somewhat difficult, but this is yet to be proven.”

Challenges to the study

People in the world’s industrialised countries are affected by viruses of the HIV-1B family and all their laboratories work on that family. This way, its PTAP-variant viral strains were known decades ago.

Although Ranga’s team had an inkling about PTAP-duplicated HIV strains in India five or six years ago, he still had to test it. The study was an international collaboration between a few Indian and South African laboratories from March 2011 to March 2015. When their initial analyses found the presence of PTAP duplication in some viral strains, the researchers decided to undertake a proper study.

To get good quality clinical samples, Ranga and his colleagues collaborated with an NGO called YRG CARE in Chennai. However, limited funds for academic research (albeit from multiple governmental agencies and departments) and lack of personnel with specialised skills like next-generation sequencing, flow-sorting and mass spectroscopy proved troublesome. So they joined hands with American collaborators and sent a PhD student to their laboratory to perform some advanced experimental work.

The most concerted efforts in HIV research around the world today are focused on HIV latency. After the virus infects the cells, it actively proliferates in some of them, setting about making daughter virus particles. In some other cells, at the same time, the virus remains dormant.

This silence is called transcriptional silence or, more popularly, HIV latency.

Ranga says that the powerful anti-retroviral medicines (ARM) can kill and remove all actively proliferating HIV from the body, but they cannot do so with the silent virus. Although this as a strategy all pathogenic organisms use to beat the immune system, HIV takes this molecular trick to the next level: by being active in some cells and silent in others at the same time. The active virus exposes the system to chronic and systemic immune activations even under successful ARM therapy.

“The systemic activation leads to rapid deterioration of the immune system. On the other hand, the silent virus becomes a technical hurdle for viral eradication.”

Antiretroviral therapy (ART) can kill the actively proliferating HIV, but not the silent HIV. And until the silent virus is removed, medicines, vaccines or any other disease management strategy will but fail.

“It is like a live bomb at home that can explode anytime,” Ranga says. “Worse, we don’t even know where the bomb is hiding in the body. We only know that there is a bomb.”

Many laboratories worldwide are engaged in developing medicines to activate the silent virus and then kill it using ART, a strategy popularly called ‘kick and kill’. The future of HIV research, therefore, is focused on reversing HIV latency – to awaken the ‘sleeping’ virus. Ranga’s lab also has active research programmes in this area.

PTAP duplication and ART

Although the study does not directly affect current treatment policies, it is likely to have a strong influence in the future. The present disease management principle is to simply control the spread of the virus; there is no cure as such.

But the great thing about the extant treatment policy – ‘test and treat’, giving antiretroviral medicines to anyone as soon as they are diagnosed to be HIV seropositive – is that an HIV infection has become virtually reclassified as a chronic disease instead of being the definite death-sentence it once was. Major awareness campaigns, mandatory tests for HIV-1 and free distribution of antiretroviral drugs helped achieve this milestone.

However, the downside is the risk of the viruses developing resistance to certain drugs and enhanced recombination, especially if people are complacent about undergoing ART every day.

But Ranga says that the problem of drug resistance in HIV is not as severe as in the case of tuberculosis (TB) for technical reasons. Compared to that of the TB bacterium, The HIV genome is much smaller than that of the TB bacterium. Thus, HIV can’t afford to have a mutated genome too long, and the virus attempts to return to the original shape when a new subject is infected. So HIV tries to remain in a drug-free zone and without a need to develop drug resistance, he explains.

However, if a population is exposed to ART much earlier and for a prolonged duration, this might change. “We have to keep our eyes open to see if HIV will pull more molecular tricks [from inside] its sleeves, such as generating more recombinant forms, creating more variant forms characterised by newer molecular properties, etc.,” Ranga says.

Despite decline, 5,008 HIV cases detected last year in Karnataka

BENGALURU: Karnataka has 2.47 lakh HIV patients, the fifth highest in the country, out of which only 1.5 lakh are receiving life-saving anti-retroviral therapy (ART).

Out of 1,951 pregnant women living with HIV only 1,421 receive this treatment. Recent advances in vaccines, early treatment, cure research, diagnostics and future drugs are being discussed at the National AIDS Conference being held here from Friday to Sunday. Among those being researched are injectables to avoid taking pills everyday and implants under the skin.

Dr G D Ravindran, Professor of Medicine, St John’s Research Institute, said, “In 2017, Karnataka had 2,47,413 HIV patients, of which 1,23,821 were women. Among them 1,55,411 (62.8%) were receiving ART. AIDS-related deaths have declined in Karnataka by 68% between 2010-2017 to 8,450. Despite a 46% decline in HIV infections in the state, we still saw 5,008 fresh HIV infections in 2017.”

Dr Glory Alexander, Director, ASHA Foundation that works for HIV patients, said, “Regarding the prevention of parent to child transmission of HIV, out of the estimated 22,677 pregnant women living with HIV in India in 2017, only 13,716 of them were receiving ART which covers only 60%. However, in Karnataka, in 2017, around 70% women were covered. 1,421 women were covered against the need of 1,951. India aims to eliminate HIV transmission from parent to child. We need to be surveillant of HIV in pregnant women to ensure we do not reverse the progress made so far.”

Need for more viral load testing machines
The World Health Organization and the National AIDS Control Organisation guidelines recommend routine viral load monitoring every six months, 12 months and then every 12 months thereafter if the patient is stable on ART. Scientific evidence has shown that if every HIV patient who is on ART has an undetectable viral load, his/her risk of transmitting HIV becomes negligible. However, viral load testing in India is done only at 10 national reference laboratories for suspected cases of treatment failure.  With the number of VLTs being so low, it is not known how many of 11.81 lakh people on ART are virally suppressed.

Vision Group to run series on HIV/AIDS starting November

World AIDS Day falls on December 1 each year

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In Uganda, 3% of adolescent girls 15-19 years live with HIV (AFP Photo)

World AIDS Day falls on December 1 each year. It is an opportunity for people worldwide to unite in the fight against HIV, to show support for people living with HIV and to commemorate those who have died from an AIDS-related illness.

Founded in 1988, World AIDS Day was the first global health day.

Package the Vision Group platforms namely: print media, TVs, radios and online will run content highlighting the achievements and challenges in the campaign against HIV/ Aids.

It will also focus on issues relating to this year’s AIDS Day theme: Know your status.

New Vision editor John Kakande said as a leading media house, Vision Group has an obligation to contribute to the fight against HIV/AIDS and hence the must-read special package.

“Over the years, New Vision newspaper and Vision Group have come up with special packages to commemorate the World AIDS Day. We devote space ahead of the World AIDS Day to highlight issues related to campaign against HIV/AIDS, to create awareness and tell our audiences the progress so far made and the challenges,” Kakande said.

He said although Uganda had made progress over the years, it is not yet time to celebrate but rather to consolidate the gains.

The New Vision health editor, Lillian Namusoke Magezi, said HIV/AIDS has taken a new face in Uganda, which calls for concerted efforts and approach.

“The series will put a historical perspective to the scourge and encourageUgandans to know their sero status. If you test positive, go for medication and if found negative, maintain your status,” she said.

Namusoke said the daily stories would empower readers with vital information to stay safe, improve the quality of life and take precautionary measures.

Bukedde TV manager, Moses Kasasa, said effective November 1, all live local programmes would have a segment on HIV/AIDS.

“We want to create awareness about HIV/AIDS and remind our viewers that the disease is still with us and we need to guard against it,” he said.

Kasasa said the TV would air profiles of people who have taken a lead role in the fight against the scourge. Places such as Lukaya, Nakibizzi, Kasensero, Rakai, Naluweerere, Mbiko, which were hard hit by HIV/AIDS will also be profiled.

HIV/AIDS burden According to global information and education on HIV and AIDS, over 1.4 million people are living with HIV, women and young girls in particular are disproportionately affected.

Uganda has lost close to two million people to the HIV. HIV remains a significant challenge to Uganda.

Its effects on the economy and society remain unacceptably high, with up to 83,000 having contracted HIV in 2016 (227 infections per day and nine infections per hour), while 28,000 died of HIV-related illnesses in the same year (77 deaths per day).

Young people, especially women and girls, are disproportionately affected.

Sixty percent of the deaths are men due their poor health services seeking behaviour.

Fewer men than women test for HIV. Uganda has a predominately young population with adolescents constituting 24.3% of the population.

According to health ministry estimates for 2015, HIV incidence (number of new HIV infections) among adolescents remains high estimated at 11,026 (11.6%).

One in every four new infections among women in Uganda occurred in adolescents and young women aged 15-24 years (GAP Report 2014).

Young women who have experienced intimate partner violence were 50% more likely to have acquired HIV than women who had not experienced violence.

In Uganda, 3% of adolescent girls 15-19 years live with HIV and the prevalence doubles 7.1% by the time they are 24 years (UAIS, 2011).

A New Model of Care: The Trans* Wellness Project

Mazzoni Center is the only health care provider in the Philadelphia region specifically targeting the unique health care needs of the lesbian, gay, bisexual, and transgender communities. Founded in 1979, it is the oldest AIDS service organization in the Commonwealth of Pennsylvania, and the fourth-oldest in the nation. As the organization has evolved to meet the needs of our constituents, Mazzoni Center has combined HIV/AIDS-related services and health services and developed a reputation for excellence and innovation in service delivery.

While society has become increasingly accepting of lesbian, gay, bisexual and transgender (LGBT) communities, many LGBT individuals still continue to face discrimination, stigma, and violence that affect their daily living. This is especially true for transgender and gender non-conforming people.  Transgender communities face rampant discrimination and barriers in every area of life.

Transgender women face some of the highest rates of HIV (20.23%), higher rates of depression and mental health issues, greater risks of violence and abuse, and have far higher rates of attempted suicide (49%) than the general population. In addition to these health disparities, they are significantly more likely to live in poverty and to lack insurance coverage. Transgender women face other risk factors associated with poverty, such as obtaining transition-related medical care from underground markets and participating in sex work industries, which put them at greater risk for contracting HIV or other STIs.

Transgender women of color are a historically underserved population and face some of the worst health outcomes in the LGBT communities.  According to the National Transgender Discrimination Survey, 21% of Black respondents reported being refused medical care due to trans or gender non-conforming status, 34% reported postponing care when they were sick or injured due to fear of discrimination, 50% reported having to teach their medical providers about transgender care and 48% reported inability to afford medical care.

We applied for funding specifically to address the barriers that trans women living with HIV face to accessing and being retained in care.  We are so lucky to have included in last year’s AIDS United Retention in Care cohort.  With the help of these funds, we have established the Trans* Wellness Project, which is focused on meeting the self-identified needs of trans communities, using a holistic and multi-faceted approach.

As part of the Trans* Wellness Project, we welcomed three peer outreach workers to our staff.  Working together with Trans* Care Coordinator, this team is focused on connecting with individual trans women through street outreach and education, talking one-on-one with the women they meet to let them know about our programs and services, along with other resources available to them in the Philadelphia area.

We’ve also introduced a bimonthly drop-in health service, which we call the T.R.U.E. Care Clinic (Trans Resources, Unity, and Education).  This collaboration between the Trans* Wellness Project and Mazzoni’s primary care practice takes place on the first and third Friday evenings of each month, at an offsite location, designed to provide privacy and reduce stigma in a very insular community.  (For hard to reach populations, we have found it is important to offer multiple, flexible service delivery points with non-traditional operating hours). We provide free, comprehensive services including: primary medical care; trans-specific medical care; HIV medical care; rapid HIV testing and STD screening; risk-reduction counseling; substance abuse/mental health assessment and referral; health education; eligibility screening and application for public benefits, and information and referral.

Patients visiting the clinic are greeted and have their intake completed by a member of the Peer Outreach Staff, who then provides a “warm handoff” to medical or social work staff.  We’ve created a relaxed environment where women know they can stop by to say hello to staff, load up on safer sex supplies, and see a medical case manager or clinician when necessary.

We are in the process of enrolling 80 trans women living with HIV into our Retention in Care Project.  Participants are referred into this program through a variety means, including in-reach (referrals provided from clinicians at Mazzoni Community and Family Medicine, as well as through Medical Case Management, and Mazzoni’s Open Door Mental and Behavioral Health program), and outreach (contacts made by our Peer Outreach Staff or through linkages with other agencies).  These participants receive targeted care coordination, designed to increase retention in care and help remove systemic barriers to accessing services and medications.

The funding from AIDS United has allowed us to engage trans women in every level of our service delivery.  At the very beginning of our project, we formed a Community Advisory Board, now called Sisterly L.O.V.E. (Leading Ourselves via Education).  Sisterly L.O.V.E. provides leadership opportunities that center the voices and experience of transgender women, especially women who are working in the sex industry, living with HIV, and those who have experienced homelessness or incarceration.  Our membership is comprises of a racially and ethnically diverse group of women, whose ages range from 20- 55 years old.

As a program developed for transgender women by transgender women, Sisterly L.O.V.E. is best able to meet the unique and always evolving needs of this particular community.  Sisterly L.O.V.E. members and Trans* Wellness Project staff coordinate monthly pyschoeducational workshops for the larger community.  Previous workshops have included sexual health and pleasure, self-defense, health relationships, job readiness, and managing depression/anxiety.  These workshops and seminars drive the services that Mazzoni Center provides for trans women across our continuum of care.

Sisterly L.O.V.E. members been instrumental in providing key training and community outreach about the needs of transgender women.  For example, Sisterly L.O.V.E. members have worked with the Philadelphia Police Department, the City of Philadelphia, and the Washington West Civic Association to ensure that trans women are treated with respect on our city’s streets and in our neighborhoods.  Additionally, members have provided trainings for medical students and regional circuit judges on best practices for working with the trans* community.  Finally, Sisterly L.O.V.E. was able to respond to the violent murder one of our community members by hosting a ‘speak-out’ and vigil that received national news coverage, drawing attention to the violence that disproportionately affects transgender women.

Mazzoni Center recognizes the importance of these efforts being driven by trans women, and how unique our program is in that regard.  As a result, Sisterly L.O.V.E. members have been providing capacity building trainings on how to increase leadership and engagement of trans women, which have been delivered at Creating Change (Houston), the Philadelphia Trans Health Conference, and the Allied Media Conference (Detroit).  Sisterly L.O.V.E. is a space where transgender women can mobilize around the issues affecting their community, building a strong coalition that is able to bring about a larger public awareness of the issues faced by trans women in Philadelphia on a daily basis.

We are extremely proud of this new model for providing HIV services to a dramatically underserved community.  By centering the voices and experiences of the women in our program in all that we do, we have been able to establish trust and build relationships, while being accountable to providing holistic and sensitive care to trans women living with HIV.

Source : Aidsunited.org

A Promising Progress Report on the National HIV/AIDS Strategy Only Tells Half of the Story

On the surface, there was nothing terribly unusual or noteworthy about the 2017 National HIV/AIDS Strategy Progress Report that was quietly released to the public last week. Aside from a few passing mentions of the incoming Trump administration and the slightest sliver of trepidation from the study’s authors at the Department of Health and Human Services’ Office of HIV/AIDS and Infectious Disease Policy, there was very little acknowledgement that there had been any significant federal policy changes concerning health care and HIV since their last report in 2016. Nowhere in the Progress Report was there any mention of the Trump administration’s repeated efforts to repeal the Affordable Care Act which has provided health care access for millions of people living with or at risk of contracting HIV, nor was their discussion of the administration’s radical attempts to undermine the Title X Family Planning Program or their failure to appoint a director of the Office of National AIDS Policy while leaving the Presidential Advisory Council on HIV/AIDS empty. For all intents and purposes, the 2017 NHAS Progress Report was created in a political vacuum, almost entirely separated from the world HIV advocates live in but for a thin strip of hope that maybe, just maybe, the political appointees at HHS and in President Trump’s inner circle will do the right thing and provide the funding and leadership needed to end the HIV epidemic in the United States.

As has been the case in past years, the 2017 NHAS Progress Report uses a set of traditional metrics to gauge success (and failure) in our nation’s domestic response to the HIV epidemic. It is a straightforward assessment of 17 indicators that are used to measure progress on NHAS goals.  They measure the growth from the initial NHAS in 2010 through the most recent data we have available.  From there, the indicators are extrapolated to see what gains we would need to see between now and 2020 to meet the targets that have been set.

Overall, the most recent batch of progress data (2014/15) on the NHAS indicators is promising, if not necessarily at the place needed to meet the targets set for 2020. Some of the highlights include:

  • Almost a 5% decrease in new infections from 2011 to 2015 (41,985 to 39,876)
  • A nearly 12% increase in people living with diagnosed HIV who were virally suppressed between 2010 and 2014 (46% to 57.9%)
  • A more than 300% increase in PrEP use between 2014 and 2015 (7,972 to 33,273)
  • Knowledge of HIV serostatus increased more than 2% between 2010 and 2014 (82.7% to 85%)

 

Overall, the most recent batch of progress data (2014/15) on the NHAS indicators is promising, if not necessarily at the place needed to meet the targets set for 2020. Some of the highlights include:

  • Almost a 5% decrease in new infections from 2011 to 2015 (41,985 to 39,876)
  • A nearly 12% increase in people living with diagnosed HIV who were virally suppressed between 2010 and 2014 (46% to 57.9%)
  • A more than 300% increase in PrEP use between 2014 and 2015 (7,972 to 33,273)
  • Knowledge of HIV serostatus increased more than 2% between 2010 and 2014 (82.7% to 85%)

At the same time, there were a number of NHAS indicators that saw significant regression since the last progress report was released. All of the negatively performing indicators were associated with the reduction of risk behaviors and disparities in HIV diagnoses among various populations, including failures to reduce HIV risk behaviors among young MSMs, homelessness, and disparities in HIV diagnosis among MSMs, young black MSMs, and people living in the South.

Outside of the statistics, the 2017 NHAS Progress Report stressed the need to continue reducing stigma and eliminating discrimination as key to ending the HIV epidemic in the United States and, very much in line with that goal, featured their take on U=U, saying that studies have shown that, “people living with HIV who take HIV medications daily as prescribed and achieve and then maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.” The Report also called for “full access to comprehensive PrEP services for those whom it is appropriate and desired”, and the need for a robust HIV-centered response to the opioid epidemic.

Unfortunately, due to the draconian budget cuts recommended by the Trump administration in both of their budgets and their aforementioned failures concerning ONAP, PACHA, Title X Family Planning, and our nation’s health care system writ large, the report does not show the full picture, and is sometimes directly at odds with, the actual National HIV response as it is occurring on the ground.

For instance, in the Report’s section detailing the most recent progress on federal actions related to NHAS, there were 26 specific examples provided to illustrate the types of activities taken by federal agencies to address NHAS indicators. Of those 26 examples, 9 of them featured projects that were funded either in whole or in part by programs that would be completely eliminated under the Trump administration’s FY19 budget. Included in this group of praised, yet at risk activities were the creation of a free online curriculum around HIV/HCV co-infection by the AIDS Education Training Centers’ National Coordinating Resource Center, a 3-year Special Project of National Significance seeking to improve system-level outcomes impacting employment, housing and health care for people of color living with HIV, and a whole host of projects funded by the Secretary’s Minority AIDS Initiative Fund benefitting a wide range of groups from adolescent sexual minority males to American Indians/Alaska Natives.

Alongside their praise of programs underneath the crosshairs of the Office of Management and Budget, the NHAS Progress Report also highlighted recent legal decisions and policies that have been directly contradicted by the actions and statements of the Trump administration. Perhaps most jarring, in the Report’s Reducing Stigma and Eliminating Discrimination section, they spotlight a legal battle that was brought on by an Oklahoma nursing home’s violation of Section 1557 of the Affordable Care Act when it illegally discharged a woman because of her HIV status. The report also fails to note that the Trump Administration has attempted on numerous occasions to dismantle the Affordable Care Act  (both through legislative efforts to repeal the law and through ongoing regulatory and administrative sabotage) as well as the health care nondiscrimination policies in Section 1557. No broader context surrounding these events is provided.

It is also worth mentioning that the statistics included in the 2017 NHAS Progress Report do not provide any insight into how the policies of the Trump administration have impacted HIV in the U.S. With the most recent data included in this year’s Report only taking us up to 2014 and 2015, it will be another 2 to 3 years before we are able to see the direct impact that President Trump and this Republican Congress have had on the NHAS indicators. At the same time, AIDS United is pleased that the report remained on schedule and that the indicators continue to be intact.  It is not too late to ensure that we stay on track to reduce HIV in the U.S. and even alter course towards a direct plan to end the epidemic.

HHS shells out more than $2 billion for HIV/AIDS care support

HIV SELF Test Kit

The federal government doled out more than $2 billion during fiscal 2018 to support medical and social services for people living with HIV/AIDS, officials said Thursday.

The Ryan White HIV/AIDS program’s fiscal 2018 funding matched its totals since 2010.

“New medical advances and broader access to treatment have helped transform HIV/AIDS from a likely death sentence into a manageable chronic disease,” HHS Secretary Alex Azar said in a released statement. “The Ryan White HIV/AIDS program is an important way to ensure that these life-saving treatments reach the Americans who need them, and the Trump administration is committed to continuing to improve the care Americans living with HIV/AIDS receive.”

It is unclear whether the total announced Thursday includes the $5.7 million that HHS reportedly planned to divert from the program to help pay for housing costs associated with the Unaccompanied Alien Children program. HHS did not respond to requests for comment as of Thursday afternoon.

As in previous years, a large portion of the funding—more than $820 million—went to states for the AIDS Drug Assistance Program, which covers the cost of providing medications to low-income individuals living with HIV/AIDS who are under-insured or uninsured.

More than $620 million was awarded to 52 cities with the largest or fastest-growing HIV populations to provide core medical and support services. Community-based organizations received $182 million to provide support through the program’s early intervention services.

The Ryan White HIV/AIDS program was created in 1991 after years of inaction to address the AIDS crisis. Now it is the largest federal program for people living with HIV/AIDS, providing services to more than 500,000 individuals. Advocates credit the program with helping reduce the annual number of new cases of HIV, which fell 5% between 2010 and 2015, from 41,800 to 38,500 new infections.

The program’s sustained funding has also been touted by many public health advocates as a possible template for the kind of effort needed to adequately address the opioid crisis. So far, lawmakers have committed more than $4 billion over the past two years toward combating the opioid crisis, with that coming via one-time funding mechanisms. But addiction medicine advocates have long estimated that it will take several billion dollars each year over the next decade to make significant progress. The epidemic led to more than 70,000 deaths in 2017, according to the Centers for Disease Control and Prevention.

More Prevention Research Needed to Control the HIV/AIDS Pandemic

Since the beginning of the HIV/AIDS pandemic, investigators have been exploring different avenues of research for how to stop transmission of the virus once and for all.

As scientific research continues to advance, experts in health care continue to discuss potential timelines for an HIV vaccine or an HIV cure, but HIV elimination and even further, eradication, are also on the minds of many.

In a plenary lecture at the HIV Research for Prevention (HIV R4P) conference, being held in Madrid, Spain, Anthony Fauci, MD, Director of the National Institute for Allergy and Infectious Disease presented a session entitled “Ending the HIV/AIDS Pandemic: The Critical Role of HIV Prevention Science.”

With 1.8 million new infections reported in 2017, Dr. Fauci explained how rather than concentrating on elimination and eradication, the research community should focus on HIV control.

He backed this argument by pointing out that smallpox is the only human disease to be eradicated worldwide and that although several other human diseases have been eliminated from certain areas of the world, none have been eradicated completely.

According to Dr. Fauci, prevention pathways toward ending the HIV/AIDS pandemic should focus on the synergy and convergence of vaccine and nonvaccine prevention.

In the category of nonvaccine prevention, elements include condoms, prevention of mother-to-child transmission, voluntary male circumcision, treatment as prevention, and pre-exposure prophylaxis (PrEP).

In his lecture, Dr. Fauci discussed the need for investigators and physicians to think realistically, not theoretically. In theory, if we could identify all individuals infected with HIV and put them on suppressive antiretroviral therapy, we could theoretically end the HIV/AIDS pandemic tomorrow, said Dr. Fauci. However, for various reasons—including rates of adherence, and barriers in surveillance—it is not realistic for that to occur.

Oral PrEP has been a successful prevention option in many populations, but it is also critical to optimize broadly neutralizing antibodies for prevention and treatment of HIV. According to Dr. Fauci, areas of research in this category should focus on pinpointing more potent antibodies and extending their half-life, analyzing vector-based antibody production in vivo, and focusing on successfully using combinations of antibodies.

In addition to clinical research, it is critical to focus on incidence “hot spots,” said Dr. Fauci. It is imperative to pinpoint where there are HIV clusters or prevalence and compare and contrast if PrEP prescriptions are being administered and filled in those areas.

In addition to geographic trends, it is also important to look at demographic trends to determine in which populations HIV cases are most prevalent.

Finally, Dr. Fauci addressed the concept of an HIV vaccine and in his opinion, it could be approached in 2 ways.

First, investigators could produce a vaccine based on the empiric approach, testing the candidate and identifying a correlate of immunity which is a typical approach to vaccinology. However, it is also possible that the vaccine could be developed by assuming a correlate of immunity and designing a vaccine to induce this correlate.

Regardless of the method, the level of efficacy required to make the vaccine acceptable worldwide is still unknown. How good is good enough?

In closing his presentation, Dr. Fauci concluded, “Development of a moderately effective vaccine together with optimal implementation of existing treatment prevention modalities could end the current HIV pandemic.”