Delaying HAART Might Prevent Complete Immune System Recuperation

People living with HIV who do not start highly active antiretroviral treatment until their CD4+ T cell counts drop below 200 might not be able to reach a normal CD4 cell count, even after 10 years of otherwise effective treatment, according to a study in the March 15 issue of Clinical Infectious Diseases, Reuters reports. According to Reuters, an HIV-positive person is considered to have a normalized immune status after CD4 counts are maintained above 500.

For the study, researchers examined 366 HIV-positive people who had maintained plasma HIV RNA levels of no more than 1,000 copies per milliliter of blood for at least four years after starting therapy. About 25% of the study's participants were followed for more than 10 years, with a median follow-up of 7.5 years. Reuters reports that 95% of the participants who started therapy with a CD4 cell count of at least 300 were able to reach a normalized CD4 cell count of at least 500. The researchers reported that 44% of participants who began treatment with a CD4 cell count of less than 100 -- as well as 25% who began treatment with a CD4 cell count of between 100 and 200 -- were not able to reach a CD4 cell count higher than 500.

Lead author Steven Deeks of the University of California-San Francisco and colleagues wrote that a "persistently low CD4 cell count during treatment is associated with increased risk of both AIDS and non-AIDS related events," such as liver disease, cardiovascular disease and cancer. They added that "novel immune-based therapeutic approaches may be necessary to restore immunocompetence in these individuals." In a related editorial, Boris Julg and Bruce Walker, both of Massachusetts General Hospital, wrote that major treatment guidelines recommend beginning antiretroviral therapy when CD4 cell counts drop below 350, adding that it can be difficult for developing and low-income countries to follow such advice. Julg and Walker wrote that "adequate early therapy, leading to more-complete immune reconstitution, may save resources because of the resulting lower incidence of opportunistic infections and reduced need for medical care" (Reuters, 4/7).

An abstract of the study is available online. An abstract of the accompanying editorial also is available online.

New Orleans Officials Should Ensure That 'Glitch' in Ryan White Process Will Not Create 'Problem' With 2009 Grants

"The grant process for agencies working with" HIV-positive people is "maddening," a New Orleans Times-Picayune editorial says. According to the editorial, it "took six months" for Mayor Ray Nagin's administration to "distribute $7 million in federal grant money this year," and the city's Office of Health Policy "received the money" from the Ryan White Program in March but did not "send out grant award notices to agencies until June." It adds that contracts were not "finalized until last month."

Following criticism from the City Council on the "slow-moving process," Health Policy Director Fran Lawless "promised that her office would do better with the next round of grants," the editorial says, adding, "Unfortunately, that hasn't been the case so far." According to the editorial, a "public notice published last week to launch the 2009 process included errors that forced the city to cancel the effort and push back its start." It adds, "Even the best operations can make the type of clerical errors in the failed notice. And there are points in the public notice process where things can occasionally go wrong." However, "these problems are worrisome considering the office's history of delays," the editorial says, adding that Nagin "needs to make sure the office's director and employees can efficiently accomplish this task or find some who can." Concerns from officials involved with the grant process "surely pal[e] in comparison with the anguish of more than 4,000 people with HIV/AIDS who get treatment and case management services from the entities that the grants fund," according to the editorial. It adds, "At least one of those agencies had to close during the summer because of the city's delays. That left hundreds of people without the help they need." The editorial concludes that city "officials promise that the glitch in the process won't cause a problem with the 2009 grants. They need to ensure that it doesn't" (New Orleans Times-Picayune, 12/22).

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Global Financial Crisis Could Adversely Effect AIDS Funding

The current global financial crisis could harm HIV/AIDS funding and increase the factors that make people vulnerable to the disease, UNAIDS Executive Director Peter Piot said on Tuesday during an event at the Center for Strategic and International Studies, CQ HealthBeat reports. According to Piot, as rising food and energy costs drive more people into poverty worldwide, the factors that drive the spread of HIV also could increase. "That must have an impact on the spread of HIV, although it's not so clear," he said, adding that it is certain that low-income countries will be more affected by and vulnerable to the financial crisis when it comes to providing HIV/AIDS treatment. For example, 100% of the cost to provide 50,000 HIV-positive people in Rwanda with antiretroviral drugs at the end of last year was paid by donors -- such as the Global Fund To Fight AIDS, Tuberculosis and Malaria and the President's Emergency Plan for AIDS Relief -- according to Piot. He added that Brazil receives no donor funding to provide similar treatment services to its HIV-positive citizens.

Countries likely will not feel the effects of the financial crisis on HIV/AIDS "in the next six or 12 months because of commitments that have been made in better times," Piot said, adding that he wonders if it will be possible to continue enrolling 700,000 to one million people in drug treatment programs over the next few years. "If not, deaths will go up again, deaths from AIDS, no doubt about it," he said, adding, "We estimate that even if (funding) continues at the same level, deaths will go up to about three million per year by 2011."

Piot also praised the Bush administration and Congress for continuing PEPFAR, which he said is an "unprecedented program that has saved millions of lives." Piot added, "It is quite rare in international development that you can count so easily, you can measure, the impact of actions, and yet this has been the case when it comes to what PEPFAR has done, and it's unprecedented in international development." In addition, Piot commended President Bush and Secretary of State Condoleezza Rice for their comments at the recent White House summit on international development about how the U.S. should not reduce aid. "I hope that the next president will follow along the same lines," Piot said.

Jennifer Kates -- vice president and director of HIV policy at the Kaiser Family Foundation -- said it is difficult to assess how the financial crisis will affect future funding levels. "How the financial crisis plays into that, we still don't know," she said.

Piot will leave his position at UNAIDS at the end of the year to head the new Institute for Global Health at Imperial College London (Vadala, CQ HealthBeat, 10/28).

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More money needed to reduce the number of new U.S. infections

CDC officials on Tuesday at a House Government Reform and Oversight Committee hearing said they would need an additional $4.8 billion dollars over the next five years to reduce the annual number of new HIV infections in the U.S., CQ HealthBeat reports (Stanchak, CQ HealthBeat, 9/16).

According to the Los Angeles Times, the hearing came after CDC released a study last month that found that about 56,300 new HIV infections occur annually in the U.S. (Dizikes, Los Angeles Times, 9/17).

CDC Director Julie Gerberding based on the new estimates the agency would need an additional $877 million in 2009 to reduce the number of new HIV infections. According to the Times, the fiscal year 2009 budget request for HIV prevention funding is $892 million, which includes $752.6 million requested by CDC. Waxman said that he would try to work with the House Appropriations Committee to increase funding for domestic HIV prevention efforts but added that he is "not very optimistic" the Bush administration will increase funding (Los Angeles Times, 9/17).

Gerberding; Kevin Fenton, director of CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; and Anthony Fauci, director of the National Institute for Allergy and Infectious Disease, told the committee that although the additional amount of money requested is high, it could reduce the HIV transmission rate by 50% over 12 years. In addition, the increased funding could help reduce the number of HIV-positive people who are unaware of their status by 50% and help reduce racial disparities.

Gerberding said that the agency would use the increased funding to expand HIV testing, research new prevention techniques and evaluate prevention programs. Fauci added that increased funding also would allow research into new areas of HIV prevention research, such as preventing coinfection with other sexually transmitted infections, providing antiretroviral drugs to HIV-negative people as a preventive measure, testing microbicides and vaccine development.

Although the $4.8 billion request is a significant amount of money, it would be more expensive not to treat HIV, Fauci said. A "professional judgment budget" (.pdf) released by the panelists noted that each HIV infection costs more than $1 million in treatment and lost productivity and that if CDC can prevent 4,800 new infections over five years, the programs established with increased funding would be "cost saving to society."

Gerberding said the request is "not just about funding, it's about needing new tools," adding, "AIDS is a social disease as well as a viral disease ... if we don't address the underpinning issues, we'll never get to where we need to be" (CQ HealthBeat, 9/16). She said that the U.S. "need[s] to do so much more than we're doing right now" to prevent new HIV infections, adding that public health workers "need to get AIDS back on the radar screen" because HIV/AIDS "is still posing a threat to college students and to young men and women across our nation's fabric."

Panelists also called for additional HIV prevention and education programs that target blacks, Hispanics and men who have sex with men. George Ayala of AIDS Project Los Angeles told committee members that only four of CDC's 49 recommended intervention programs specifically target MSM and only one targets minority MSM. He said, "Serious HIV-related health disparities, often fueled by stigma and discrimination, continue to undermine HIV prevention efforts in communities of color" (Los Angeles Times, 9/17).