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SEPTEMBER 2006
News and Literature Reviews
CDC Releases Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings The Center for Disease Control and Prevention (CDC) released Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings in the September 22 issue of Morbidity and Mortality Week Report (MMWR). The new recommendations are intended to integrate voluntary HIV testing into routine medical care and to increase early HIV diagnosis among the estimated one of four persons with HIV infection in the U.S. who are not aware of their HIV-positive status. The recommendations include voluntary HIV screening for all persons between the ages of 13 and 64 years as a standard practice of medical care. The recommendations also include an opt-out provision, allowing for patients to refuse testing after they have received basic information regarding HIV testing and treatment. To simplify HIV screening the CDC recommendations no longer require pre-test counseling and written consent, although the authors emphasize the importance of offering HIV-positive individuals post-test prevention counseling and access to care. Finally, the CDC contends that pregnant women at high risk for HIV or in areas with high HIV prevalence should be routinely tested for HIV in their third trimester. The report also recommends that rapid HIV tests be used for all women with unknown HIV status during labor. In early 2007, the CDC will issue further guidelines for providers, including practical tools and model approaches for implanting these recommendations. CDC. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. Morb Mortal Wkly Rep.2006;55(RR14);1-17. Available at: http://www.cdc.gov/mmwr/preview /mmwrhtml/rr5514a1.htm Prison Research Group Honored by CDC The Prison HIV Seroincidence Group of the CDC Division of HIV/AIDS Prevention (DHAP), received the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Director's Recognition Award for September. From September 2004 to April 2006, the Prison HIV Seroincidence Group conducted the first large-scale investigation into HIV transmission in a prison system in the U.S. (see IDCR May 2006). The Group worked collaboratively with prisons and health department personnel, interviewed 226 prisoners and 8 correctional officers in 31 Georgia prisons, and conducted focus groups with ex-inmates. In addition, they obtained blood samples from the inmates, reviewed inmate medical charts, conducted HIV testing, HIV phylogenetic testing, and HIV antiretroviral resistance testing. The Group collected data on illegal and stigmatizing sex and drug behaviors in prison and the contexts and dynamics that place inmates at risk for HIV infection, and made recommendations for HIV prevention in corrections. The Group's investigations identified and confirmed 88 cases of HIV transmission that occurred among inmates during incarceration and identified factors associated with HIV seroconversion. They also demonstrated the existence of several clusters of ongoing HIV transmission as evidenced by seroconverters sharing common HIV strains. House Bill Would Require Federal Prisons to Provide HIV Testing for Inmates Early this month, California Representative Maxine Waters (D) introduced a bill to the House that would require HIV testing for all federal prison inmates upon entry. The bill also includes an opt-out choice for inmates who do not wish to be tested. The opt-out provision acknowledges the complex issues of stigma and confidentiality often connected to HIV-positive status. Additionally, to foster a continuum of care from prison to the community, Waters' bill would require the Bureau of Prisons to contact former HIV-infected inmates and direct them to treatment and counseling in the community. Although the Bureau of Prisons' policies already emphasis the importance of testing inmates, Waters contends that under her bill more inmates will be tested and have greater access to care upon release. Skeptics question the effectiveness of a bill that includes an opt-out provision since there is no way to tell just how many inmates would refuse HIV testing. Waters seeks to sway AIDS groups on prisoner testing. Young J. The Hill. September 12, 2006. Available at www.thehill.com. HIV/AIDS, Sexually Transmitted Diseases (STDs) and Incarceration Among Women This large-scale retrospective study utilized secondary data from federal and state corrections agencies to examine the relationship between incarceration and HIV and STD trends - focusing on black women living in poverty in the rural south. Across the U.S., Hammett and colleagues observed that an increasing proportion of inmates are women, with disproportionate representation of black and Latino women. Of all regions, incarceration rates were highest in the South (790 per 100,000), but unlike other areas, the South displayed similar rates of incarceration between urban and rural residents. The national prevalence of HIV and STDs was higher in female inmates (for HIV 3%) than in incarcerated males (for HIV 2%), and women releasees from the South suffer from one of the highest regional burdens of HIV with 15% of all Southern women released from a correctional facility living with HIV. These data indicate that the overlapping of the epidemics of HIV/STDs and incarceration is greatest in the Southern U.S. Yet, despite the high prevalence of HIV among women involved in the criminal justice system in the South, it appears that only a small percentage (0.6-0.7%) of reported AIDS cases among women are diagnosed in prisons and jails. In response to this situation, the authors highlight the importance of deploying programs to prevent, diagnose, and treat individuals both within correctional facilities and rural community post release. Hammett T, Drachman-Jones A. Sexually Transmitted Diseases. 2006;33(7):S17-22 Predictors of Post-Release Primary Care Utilization Among HIV-positive Prison Inmates: A Pilot Study Recognizing the importance of the post-release period to the continuity of care in HIV positive inmates, researchers in Texas set out to examine (1) the proportion of HIV positive inmates utilizing primary care after release and (2) the variables associated with the utilization of primary care in the immediate post-release period. This pilot study of sixty inmates, both male and female, utilized qualitative and quantitative measures, obtained during interviews conducted three months prior to release and seven to twenty one days after release. They found that only 60% of the participants not lost to follow-up (n=30) utilized a primary care facility within the twenty one day post-release period. Variables positively associated with primary care usage included: receiving anti-HIV medications at the time of release, no alcohol usage since release, living in the same location as prior to incarceration, and a rating of housing situation as "comfortable" or "very comfortable." A logistical regression model comprised of these four variables correctly classified 80% of the cases in care overall. The generalizability of the findings is limited by the small sample size, an issue that the researchers plan to address in future studies. Harzke A, Ross M, Scott D. AIDS Care. 2006;18(4):290-301 Therapy After Sustained Virologic Suppression Multiple studies have attempted to simplify multi-drug antiretroviral therapies in order to reduce long-term adverse effects, expense, and difficulty of regimen adherence (See Main Article). The AIDS Clinical Trials Group (ACTG), A5201 Study Team, selected a ritonavir-boosted atazanavir (Reyataz) approach to explore this possibility. They proposed that the low-pill burden, once-daily dosing, safety, and unique resistance profile of atazanavir/ritonavir would make it a strong candidate for simplified maintenance therapy. In this multi-center pilot study 34 HIV-positive participants with persistent HIV RNA levels below 50 copies/mL while receiving their first protease inhibitor antiretroviral regimen. All had their protease inhibitor switched to atazanavir/ritonavir at study entry and the nucleosides discontinued at six weeks. Over the 24 week study period, the investigators observed an absence of virologic failure - defined as two consecutive HIV-1 RNA measurements of ?200 copies/mL - in 91% (31 of 34) of the subjects. Additionally, there were no treatment discontinuations for adverse events following simplification, no significant changes in CD4+ cell counts or plasma lipid levels, and no detectable HIV-1 RNA in seminal plasma from the eight participants providing semen. Resistance testing in the three participants exhibiting virologic failure did not identify protease inhibitor resistance mutations, while 2 of the 3 participants experiencing failure exhibited plasma atazanavir concentrations low or below detection - suggesting potential suboptimal adherence to the study regimen. These results suggest that ritonavir boosted atazanavir may be efficacious in for simplified maintenance therapy in selected patients with HIV infection and, at the least, is worthy of further investigation. Swindells A, DiRienzo G, Wilkin T, et al. the AIDS Clinical Trials Group 5201 Study Team. JAMA. 2006;296:806-14.
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