Viral load as low as 400 copies/ml six months after starting ART is associated with a significant ten-year mortality risk

Michael Carter
Published: 05 July 2017

A viral load as low as 400 copies/ml six months after starting HIV therapy is associated with a substantial ten-year mortality risk, investigators from the United States report in the online edition ofAIDS. People with a viral load between 400 and 999 copies/ml had a 20% mortality risk, similar to the 23% risk observed in people with a viral load between 1000 and 4 million copies/ml. In contrast, the mortality risk was only 14% for individuals who rapidly achieved complete viral suppression – a viral load below 20 copies/ml.

“A single viral load measurement collected six months after initiating ART [antiretroviral therapy] remains highly informative regarding the risk of death over 10 years,” write the authors.

The aim of ART is rapid and sustained suppression of viral load to below the limit of detection (between 50 to 20 copies/ml depending on testing assay). Treatment guidelines suggest that viral load should be undetectable six months after the initiation of treatment. Newer antiretroviral drug combinations, especially those containing an integrase inhibitor, suppress viral load more rapidly.

Ongoing low-level viral replication despite therapy is associated with the emergence of drug-resistant virus, causing treatment failure and an increase in the risk of HIV- and non-HIV-related illnesses. Small increases in viral load once complete suppression has been achieved, above the limit of detection on occasional tests, so-called viral load `blips`, do not predict treatment failure and are not problematic. This study looked at the failure of treatment to achieve viral suppression after six months.

Analysing viral load measurements taken six months after ART initiation, a team of US investigators sought to determine the level of low-level viraemia (up to 1000 copies/ml) which was associated with an increased risk of all-cause mortality over ten years.

Their study population consisted of approximately 8000 adults who initiated ART between 1998 and 2014. Study participants were followed until death or for up to ten years.

Median age at baseline was 40 years; 83% of participants were male; 62% were in the men who have sex with men risk group; 45% were white and 12% reported ever injecting drugs. The median pre-ART viral load was 75,000 copies/ml and the median year of ART initiation was 2007. Approximately a third of people had been diagnosed with AIDS before starting treatment.

The median period of follow-up was 6.2 years, during which time there were 863 deaths.

Over half (57%) of viral load measurements six months after starting therapy were below 20 copies/ml, with 15% measured at 1000 copies/ml or higher.

As expected, compared to a viral load below 20 copies/ml, a viral load above 999 copies/ml was strongly associated with an increased risk of all-cause mortality over ten years (HR = 1.96; 95% CI, 1.56-2.46). A slightly increased risk of mortality was discernible at a viral load as low as 130 copies/ml (HR = 1.39; 95% CI, 1.02-1.88).

“While we observed an increased hazard of death with low-level viral loads, discernible at 130 copies/ml,” write the authors, “this association was largely driven by the elevated mortality risk experienced by patients with viral load between 400 and 999 copies/ml.”

The average ten-year mortality risk for people with a viral load below 20 copies/ml was 13%, similar to the 14% risk observed in individuals with a viral load between 20 and 400 copies/ml. The ten-year mortality risk was 20% for people with a viral load between 400 and 999 copies/ml, comparable to the 23% risk for people with a viral load of 1000 copies/ml or higher.

“Low-level viral loads between 400 and 999 copies/ml shortly after starting ART appear to place patients at a significantly higher 10-year risk of death than patients with viral loads under 20 copies/ml, and occurrences of viral loads in this range may need to be treated similarly as viral load that exceed 1000 copies/ml,” conclude the authors. “Given the importance of rapidly achieving virologic suppression after initiating treatment, further investigation of the causes of unsuppressed viral loads between 400 and 999 copies/ml is warranted.”

The authors suggest that incomplete viral suppression six months after starting treatment may be a marker for several problems. Apart from lack of adherence to treatment or poor retention in care, incomplete viral suppression might be a consequence of undetected drug resistance, or of drug-drug interactions that lead to low levels of antiretroviral drugs. Planning in advance to prevent these problems from undermining treatment, and prompt investigation of any problems, are likely to improve the chances of viral suppression

Upcoming Support Group Meeting 5/18

Good Morning PMBSGN NETWORK MEMBERS and AREA 15 PROVIDERS;
This is to remind of our upcoming support group meeting at Avenue C Site # 2, ON 5/18  from 5pm – 7pm.  Please confirm with us if you are planning to attend this meeting or any provider that know of a client wanting or needing to attend.
Please have them call us directly. ASAP. 772-453-1067  Cell / 772-577-6430 Office.
Be Safe, Be Wise, don’t Hesitate to Educate!

 

 

 

AvenueCMay2016

Documentary About HIV/AIDS in the 1980s to Debut on CNN

 

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Michael S. Gottlieb, M.D., Immunologist, UCLA Medical Center

CNN will present “The Fight Against AIDS” on Thursday, May 12, 2016, at 9 p.m. as part of its documentary series The Eighties. The seven-part series focuses on the events that shaped the ’80s—a decade that included President Ronald Reagan, the end of the Cold War, Wall Street corruption, the tech boom, the expansion of television and the beginning of the AIDS crisis.

“The Fight Against AIDS” chronicles the history of HIV/AIDS through archival footage and interviews with journalists, historians, doctors, researchers, celebrities and activists. It traces the AIDS crisis from the epidemic’s beginning—when young, sexually active gay men, Haitian refugees, drug users and hemophiliacs were among the first known cases—to the panic and hysteria that resulted from the uncertainty, misinformation and ignorance surrounding the virus; and on to Hollywood’s involvement and gay-rights activists’ struggles to pressure the government to find a treatment and cure.

Highlights include the development of test kits, the impact of Rock Hudson’s AIDS diagnosis upon public awareness, the harassment of Ryan White and his subsequent activism, the Reagan controversy, and the mobilization of the LGBT community. The documentary, however, touches only briefly upon the epidemic in Black America, which the media and many other mainstream organizations largely ignored.

Gay-rights activists Cleve Jones and Larry Kramer; immunologist Dr. Anthony S. Fauci, who has been director of the National Institute of Allergy and Infectious Diseases since 1984; immunologist and HIV researcher Dr. Michael Gottlieb; and Black AIDS Institute founder, president and CEO Phill Wilson are among the pioneers in fighting the epidemic who are featured in the episode, which is definitely worth watching.

April Eugene is a Philadelphia-based writer.

 

 

 

Executive Order — HIV Care Continuum Initiative

EXECUTIVE ORDER

– – – – – – –

ACCELERATING IMPROVEMENTS IN HIV PREVENTION AND CARE IN THE UNITED STATES THROUGH THE HIV CARE CONTINUUM INITIATIVE

By the authority vested in me as President by the Constitution and the laws of the United States of America, and in order to further strengthen the capacity of the Federal Government to effectively respond to the ongoing domestic HIV epidemic, it is hereby ordered as follows:

Section 1. Policy. Addressing the domestic HIV epidemic is a priority of my Administration. In 2010, the White House released the first comprehensive National HIV/AIDS Strategy (Strategy), setting quantitative goals for reducing new HIV infections, improving health outcomes for people living with HIV, and reducing HIV-related health disparities. The Strategy will continue to serve as the blueprint for our national response to the domestic epidemic. It has increased coordination, collaboration, and accountability across executive departments and agencies (agencies) with regard to addressing the epidemic. It has also focused our Nation’s collective efforts on increasing the use of evidence-based approaches to prevention and care among populations and in regions where HIV is most concentrated.

Since the release of the Strategy, additional scientific discoveries have greatly enhanced our understanding of how to prevent and treat HIV. Accordingly, further Federal action is appropriate in response to these new developments. For example, a breakthrough research trial supported by the National Institutes of Health showed that initiating HIV treatment when the immune system was relatively healthy reduced HIV transmission by 96 percent. In addition, evidence suggests that early treatment may reduce HIV-related complications. These findings highlight the importance of prompt HIV diagnosis, and because of recent advances in HIV testing technology, HIV can be detected sooner and more rapidly than ever before.

Based on these and other data, recommendations for HIV testing and treatment have changed. The U.S. Preventive Services Task Force now recommends that clinicians screen all individuals ages 15 to 65 years for HIV, and the Department of Health and Human Services Guidelines for Use of Antiretroviral Agents now recommends offering treatment to all adolescents and adults diagnosed with HIV.

Furthermore, ongoing implementation of the Affordable Care Act provides a historic opportunity for Americans to access affordable, quality health care. The Act is expanding access to recommended preventive services with no out-of-pocket costs, including HIV testing, and, beginning in 2014, insurance

companies will not be able to deny coverage based on pre-existing conditions, including HIV. Starting October 1, 2013, Americans can select the coverage that best suits them through the new Health Insurance Marketplace, and coverage will begin January 1, 2014.

Despite progress in combating HIV, important work remains. Since the publication of the Strategy, data released by the Centers for Disease Control and Prevention show that there are significant gaps along the HIV care continuum — the sequential stages of care from being diagnosed to receiving optimal treatment. Nearly one-fifth of the estimated 1.1 million people living with HIV in the United States are undiagnosed; one-third are not linked to medical care; nearly two-thirds are not engaged in ongoing care; and only one-quarter have the virus effectively controlled, which is necessary to maintain long-term health and reduce risk of transmission to others.

In light of these data, we must further clarify and focus our national efforts to prevent and treat HIV infection. It is the policy of my Administration that agencies implementing the Strategy prioritize addressing the continuum of HIV care, including by accelerating efforts to increase HIV testing, services, and treatment along the continuum. This acceleration will enable us to meet the goals of the Strategy and move closer to an AIDS-free generation.

Sec. 2. Establishment of the HIV Care Continuum Initiative. There is established the HIV Care Continuum Initiative (Initiative), to be overseen by the Director of the Office of National AIDS Policy. The Initiative will mobilize and coordinate Federal efforts in response to recent advances regarding how to prevent and treat HIV infection. The Initiative will support further integration of HIV prevention and care efforts; promote expansion of successful HIV testing and service delivery models; encourage innovative approaches to addressing barriers to accessing testing and treatment; and ensure that Federal resources are appropriately focused on implementing evidence-based interventions that improve outcomes along the HIV care continuum.

Sec. 3. Establishment of the HIV Care Continuum Working Group. There is established the HIV Care Continuum Working Group (Working Group) to support the Initiative. The Working Group shall coordinate Federal efforts to improve outcomes nationally across the HIV care continuum.

(a) Membership. The Working Group shall be co-chaired by the Director of the Office of National AIDS Policy and the Secretary of Health and Human Services or designee (Co-Chairs). In addition to the Co-Chairs, the Working Group shall consist of representatives from:

(i) the Department of Justice;

(ii) the Department of Labor;

(iii) the Department of Health and Human Services;

(iv) the Department of Housing and Urban Development;

(v) the Department of Veterans Affairs;

(vi) the Office of Management and Budget; and

(vii) other agencies and offices, as designated by the Co-Chairs.

(b) Consultation. The Working Group shall consult with the Presidential Advisory Council on HIV/AIDS, as appropriate.

(c) Functions. As part of the Initiative, the Working Group shall:

(i) request and review information from agencies describing efforts to improve testing, care, and treatment outcomes, and determine if there is appropriate emphasis on addressing the HIV care continuum in relation to other work concerning the domestic epidemic;

(ii) review research on improving outcomes along the HIV care continuum;

(iii) obtain input from Federal grantees, affected communities, and other stakeholders to inform strategies to improve outcomes along the HIV care continuum;

(iv) identify potential impediments to improving outcomes along the HIV care continuum, including for populations at greatest risk for HIV infection, based on the efforts undertaken pursuant to paragraphs (i), (ii), and (iii) of this subsection;

(v) identify opportunities to address issues identified pursuant to paragraph (iv) of this subsection, and thereby improve outcomes along the HIV care continuum;

(vi) recommend ways to integrate efforts to improve outcomes along the HIV care continuum with other evidence-based strategies to combat HIV; and

(vii) specify how to better align and coordinate Federal efforts, both within and across agencies, to improve outcomes along the HIV care continuum.

(d) Reporting.

(i) Within 180 days of the date of this order, the Working Group shall provide recommendations to the President on actions that agencies can take to improve outcomes along the HIV care continuum.

(ii) Thereafter, the Director of the Office of National AIDS Policy shall include, as part of the annual report to the President pursuant to section 1(b) of my memorandum of July 13, 2010 (Implementation of the National HIV/AIDS Strategy), a report prepared by the Working Group on

Government-wide progress in implementing this order. This report shall include a quantification of progress made in improving outcomes along the HIV care continuum.

Sec. 4. General Provisions. (a) Nothing in this order shall be construed to impair or otherwise affect:

(i) the authority granted by law to an executive department, agency, or the head thereof; or

(ii) the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.

(b) This order shall be implemented consistent with applicable law and subject to the availability of appropriations.

(c) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.

BARACK OBAMA

Gentleman’s Night Out IRC.

This was IRC area 15 first MSM Gentleman’s Night Out Dinner. This event coordinated by AHF/ IRCHAN / IRCHD / PC/ SLCHD / LGBT  and PMBSG Network. This event had a great turn out and many PLWHA from our area attended this event. We would like to thanks to all who gave their time and participated this event.

Special Enrollment Period ends April 30

Don’t let this Opportunity Pass!!!

Millions of people have already signed up for 2015 coverage, and 8 out of 10 who enroll are getting financial help.

Don’t miss the chance to enroll in health coverage for 2015 if you owe the fee.

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This is too important to put off. If you don’t have coverage for the remainder of 2015 you’ll risk having to pay the fee again next year for the portion of the year you don’t have coverage. If you don’t have health coverage for 2015, the fee is $325 per person or 2% of your household income – whichever is higher.

We hope you take advantage of this extended opportunity to get quality coverage this year.

The HealthCare.gov Team

Rare Case of HIV Transmission between Lesbians

Sharing of sex toys may be the cause

An extremely rare case of female-to-female sexual transmission of HIV has been reported in the U.S. The report concerns a 46-year-old woman who appears to have acquired HIV during a six-month monogamous serodiscordant sexual relationship with a 43-year-old woman. The case is reported in the March 14 edition of the Center for Disease Control & Prevention’s (CDC) Morbidity and Mortality Weekly Report.

The patient’s female partner was diagnosed with HIV in 2008. The partner started antiretroviral therapy in February 2009 but stopped in November 2010, dropping out of HIV care in January 2011.

The newly diagnosed woman had no other recent risk factors for HIV. Nor were any identified in her past. That her current female sexual partner was the likely source of her HIV infection was confirmed by a technique called phylogenetic analysis, which showed that the genetic sequences of the viruses infecting the two women were highly related.

The latest case was reported to the CDC in August 2012. The woman who acquired HIV regularly sold plasma to supplement her income and had a negative HIV antibody screen when donating plasma in March 2012. However, 18 days later, an attempt by the patient to donate plasma was refused because HIV antibodies were detected. She also reported experiencing symptoms of serconversion—fever, vomiting, other flu-like symptoms. Repeat testing confirmed the woman had HIV.

Confirmed cases of female-to-female transmission of HIV via sexual contact are extremely rare. However, possible modes of female-to-female transmission during sex include exposure to vaginal or other body fluids, blood from menstruation, or blood from damage sustained during rougher sex. Another rare case a decade ago was reportedly attributed to sharing of sex toys.

The couple reported routinely having unprotected (using no barrier precautions) oral and vaginal contact and using insertive sex toys that were shared between them but were not shared with any other persons. They described their sexual contact as at times rough to the point of inducing bleeding in either woman. They also reported having unprotected sexual contact during the menses of either partner.

“This report describes likely female-to-female transmission of HIV-1 supported by phylogenetic analysis in a WSW [women who have sex with women] couple who had unprotected sex during a six-month monogamous relationship,” conclude the authors. “Although rare, HIV transmission between WSW can occur. All persons at risk of HIV, including all discordant couples, should receive information regarding the prevention of HIV.”

The newly infected woman’s partner had a viral load of 69,000 copies/ml, a level that is known to be infectious. The authors therefore believe the case underscores the importance of retaining patients with diagnosed infection in long-term care, as “control of HIV infection with suppression of viral load can result in better health outcomes and a reduced chance of transmitting HIV to partners.”