Nathan.qxp 31/7/08 11:03 am Page 24
HIV and AIDS
Medical Options in Preventing and Controlling HIV
a report by
Mayura Nathan
Head, Department of Genito-urinary Medicine, Homerton University Hospital Foundation Trust, London
It has been estimated that 2.5 million people worldwide were infected by 100 person-years of 3.8% in women and 2.3% in men were
HIV in 2007.
1
Although treatment options for those infected by HIV may be observed.
6
The likelihood of HIV acquisition rose as the distance
improving, the vast majority of those with HIV do not have access to decreased between the individual’s home and the closest primary road
appropriate care or antiretroviral medications. Furthermore, vaccine and the distance increased between the next government clinic and
development efforts are unlikely to be of benefit in preventing the spread of the individual’s home.
HIV across the world for at least another decade. The continued recognition
of new and varied recombinant HIV subtypes does not bode well for the Mortality Rates
future. Therefore, it is clear that the prevention and control of the spread of Late diagnosis of HIV inevitably increases the mortality rates of
HIV should be the major thrust in our approach to this epidemic. the infected. Short-term mortality rates declined concurrently with the
availability of ART between 1993 and 2002 in England and Wales.
7
Undiagnosed Cases However, the estimated short-term mortality was 14% for men who
A large pool of undiagnosed HIV infection exists in the world and, although have sex with men (MSM) who were diagnosed late (CD4 cell count
this applies more to resource-poor settings, it is by no means uncommon in <200x10
6
/l at diagnosis) compared with 1% for other MSM (adjusted
developed nations. In a nationally representative cross-sectional sample of odds ratio 10.8, 95% confidence interval [CI] 7.7–15.9). A similar
Ugandans, 6.3% HIV positivity was ascertained through serological testing analysis of 16,375 heterosexuals diagnosed between 2000 and 2004
of 18,525 people;
2
79% of positive cases did not know their HIV status showed that 42% were diagnosed late.
8
Short-term mortality was
before the study. A cross-sectional survey of men in commercial gay venues 6.1% among those diagnosed late (CD4 cell count <200 at diagnosis)
across the UK found 318 from a sample of 3,501 men (9.1%) to be compared with 0.7% among others (p<0.01). In the US, the Centers
HIV-positive through an oral fluid test;
3
131 of these 318 men (41.2%) were for Disease Control and Prevention (CDC) estimated that about one
unaware of their HIV status. million people were living with HIV/AIDS during 2003, and due to lack
of testing about 25% were unaware of their condition.
9
In its
Survival rates for an HIV-positive person are improved when antiretroviral HIV-testing guidelines in 2006, the CDC recommended routine testing
therapy (ART) is available and early diagnoses are made. For example, in rural in all US medical settings of those aged 13–64 years.
10
However,
South Africa, where an ART programme was introduced in late 2004, the several barriers to testing were identified in the US, including time
age-standardised mortality rate for 25–49-year-olds almost halved from factors, consenting process, lack of knowledge/training and lack of
0.0338 deaths per person-year in the first semester of 2003 to 0.0186 in the patient acceptance, among many others.
11
second semester of 2006.
4
Early Diagnosis
HIV Transmission in Discordant Relationships A study looking at the opportunities missed for early diagnosis of HIV
Between 2005 and 2006 a home-based HIV counselling and testing in London between 2004 and 2006 found that 76.4% (181/237) had
programme in Uganda tested 222,690 people, with 4.6% positive seen their GP, 38.3% (98/256) had attended outpatient services and
cases (males 3.5%, females 5.5%). Among the 829 individuals in 15.2% (39/257) had attended inpatient services in the year prior to
discordant partnerships who reported having sexual intercourse in the their HIV diagnosis.
12
At HIV diagnosis, 49.8% had advanced disease
previous three months, 744 (89.7%) never used condoms.
5
Between (CD4 <200). As well as helping the individual in his or her health
2003 and 2005, in a rural South African community where a high outcome, early diagnosis helps in preventing transmission. A meta-
prevalence (22.5%) already existed, crude HIV-incidence rates per analysis comparing the prevalence of high-risk sexual behaviours in
HIV-positive persons aware of their diagnosis versus HIV-positive
persons unaware of their diagnosis found a 68% reduction in
Mayura Nathan is Head of the Department of Genito-urinary
Medicine and a consultant physician at Homerton University
unprotected anal or vaginal intercourse in those aware of their
Hospital Foundation Trust, London, where he also leads HIV-positive status.
13
The findings were similar for men and women. A
research on human papillomavirus-related cancers affecting
study in Uganda found that those who knew their HIV status were
HIV-infected people. He became a consultant physician in
1987 and worked in Yorkshire and Nottinghamshire before
three times more likely to use a condom, and those who knew the HIV
returning to London. He contributes to a number of
status of their partners were 2.3 times more likely to use condoms.
2
regional and national committees. Dr Nathan trained in
genito-urinary medicine between 1984 and 1987 at St
Several point-of-care tests are being validated, some based on blood
Bartholomew’s and Homerton Hospitals. and others based on other body fluids such as oral fluid samples. These
E:
mayura.nathan@homerton.nhs.uk
tests should in the near future enable rapid and cheaper testing both
in the community and healthcare setting.
24 © TOUCH BRIEFINGS 2008
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