Tuberculosis Outbreak Shakes Wisconsin City

Looking crisp and official in his khaki-colored sheriff’s department polo shirt, Steve Steinhardt says Sheboygan, Wis., is a pretty good place to be a director of emergency services.

“Nothing bad happens here,” he says, knocking on wood. Unless, that is, you count the tuberculosis outbreak that struck the orderly Midwestern city of 50,000 this spring and summer.

“I never expected TB to be one of the bigger emergencies I’d face when I got into this field,” Steinhardt says.

Steve Steinhardt has led Sheboygan County’s emergency response to the nine tuberculosis cases recorded since April.

Jeffrey Phelps/For NPR

Sheboygan County officials have had to scramble to contain it. At the height of the crisis, the county activated its emergency operation center — a step usually reserved for major fires, floods and tornadoes.

The county has had to borrow personnel from other jurisdictions, calm parents of schoolchildren, find housing to isolate infected families and appeal to the state for millions of dollars in extra money to deal with the situation.

It’s a reminder that TB — a disease most Americans may view as a relic of the 19th century — is still an insidious threat that can pop up anywhere.

Read the full article including quotes from CFAR Director Richard Chaisson.

Announcing the CFAR Internal Scientific Review Process

 

CFAR Internal Scientific Review Process:

1. John Hopkins University Faculty members applying for non-CFAR funding in the area of HIV/AIDs are able to request an internal scientific review of their grant application.
   1. Internal Scientific Review is NOT available for the CFAR Faculty Development or International Research awards
   2. Letters of Intent requesting review must be submitted AT LEAST one month before grant deadline.
   3. LOIs will be submitted to the CFAR administrator and should include:
      1. Name, affiliation, contact information for applicant
      2. Grant being applied for
      3. Title of study
      4. Co-investigators
      5. Mentor
      6. Any areas of particular need of review that the applicant feels would be helpful
      7. Suggestions for reviewers (not guaranteed to be assigned)
      8. h.      Study Aims
      9. The Developmental Core with the Executive Committee will assign reviewers based on topic.  Reviewers are requested to provide feedback to the applicant on the Study Aims as soon as possible.
      10. NO LATER THAN two weeks prior to the internal grant due date (date due to ORA), the applicant will submit the research project plan to the CFAR administrator.  It does not have to be the final version, but it should be fully developed.
          1. The earlier the research plan is submitted, the better.  If there are an overwhelming number of applications submitted, they will be reviewed on a first come, first serve basis.
          2. 2 Reviewers will evaluate the proposal and provide written feed back to the applicant.  A call or face-to-face meeting may be requested by the reviewers.  The CFAR administrator is available to assist with compiling the comments, scheduling calls, etc.
             1. NIH review criteria should be used by the reviewers, however unlike a NIH review, no scoring will take place and suggestions for improvement in the proposal are encouraged.

Please note: If you would like a biostatistics or ethics consult, this should take place well before the scientific review via the CFAR services request process.  More information about service requests can be found on the web site (Hopkinscfar.org) or by sending an e-mail to cfar@jhmi.edu

Review Criteria:

(1) Significance: Does this study address an important problem? If the aims of the application are achieved, how will scientific knowledge be advanced? What will be the effect of these studies on the concepts or methods that drive this field?

(2) Approach: Are the conceptual framework, design, methods, and analyses adequately developed, well-integrated, and appropriate to the aims of the project? Does the applicant acknowledge potential problem areas and consider alternative tactics?

(3) Innovation: Does the project employ novel concepts, approaches or method? Are the aims original and innovative? Does the project challenge existing paradigms or develop new methodologies or technologies?

(4) Investigator: Is the investigator appropriately trained and well suited to carry out this work? Is the work proposed appropriate to the experience level of the principal investigator and other researchers (if any)?

(5) Environment: Does the scientific environment in which the work will be done contribute to the probability of success? Do the proposed experiments take advantage of unique features of the scientific environment or employ useful collaborative arrangements? Is there evidence of institutional support?

6) Transdisciplinary nature of the research.  Proposals which successfully bring more than one scientific discipline to bear on research questions of interest will receive additional partial point scoring to encourage transdisciplinary research.

Stem-cell transplants may purge HIV

(Nature)

Two men with HIV may have been cured after they received stem-cell transplants to treat the blood cancer lymphoma, their doctors announced today at the International AIDS Society Conference in Kuala Lumpur.

One of the men received stem-cell transplants to replace his blood-cell-producing bone marrow about three years ago, and the other five years ago. Their regimens were similar to one used on Timothy Ray Brown, the ‘Berlin patient’ who has been living HIV-free for six years and is the only adult to have been declared cured of HIV. Last July, doctors announced that the two men — the ‘Boston patients’ — appeared to be living without detectable levels of HIV in their blood, but they were still taking antiretroviral medications at that time.

Timothy Henrich, an HIV specialist at Brigham and Women’s Hospital in Boston, Massachusetts, who helped to treat the men, says that they have now stopped their antiretroviral treatments with no ill effects. One has been off medication for 15 weeks and the other for seven. Neither has any trace of HIV DNA or RNA in his blood, Henrich says.

If the men stay healthy, they would be the third and fourth patients ever to be cured of HIV, after Brown and a baby in Mississippi who received antiretroviral therapy soon after birth.

But Henrich and Daniel Kuritzkes, a colleague at Brigham who also worked with the men, caution that it is still too early know whether or not the Boston patients have been cured. For that, doctors will need to follow the men closely for at least a year, because the virus may be hiding out in ‘reservoirs’ — parts of the men’s bodies, such as their brain or gut, that can harbour the virus for decades.

“We’re being very careful not to say that these patients are cured,” Kuritzkes says. “But the findings to date are very encouraging.”

HIV researcher Steven Deeks of the University of California, San Francisco, says that doctors might need to wait at least two years before declaring that a cure has been achieved. “Any evidence that we might be able to cure HIV infection remains a major advance,” Deeks says. But, he adds, “there have been cases of patients who took many weeks off therapy before the virus took off”.

Read the full article here.

ESRD rate almost fourfold higher in HIV population

(Healio)

The rate of end-stage renal disease was nearly four times greater in HIV-infected adults relative to the general population in the United States, according to new data presented at the 2013 International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Kuala Lumpur, Malaysia.

Researchers said the data indicate “the need for greater surveillance, prevention, and treatment of comorbidities among HIV-infected adults.”

Keri N. Althoff, PhD, MPH, assistant professor in the department of epidemiology at Johns Hopkins Bloomberg School of Public Health, and colleagues identified participants from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) with at least two estimated glomerular filtration rates less than 30 mL/min/1.73 m³ measured more than 90 days apart or a diagnosis of renal disease from 2000 to 2009. The researchers validated end-stage renal disease (ESRD), defined as dialysis or renal transplant, through medical record review and used Poisson regression analyses to determine crude incidence rates (IR) and incident rate ratios (aIRRs) adjusted for age, sex, race, HIV transmission risk, antiretroviral treatment, clinical AIDS diagnosis, undetectable HIV viral load, and CD4 count. Age- and sex-standardized incidence ratios (SIRs) were estimated to compare the HIV-infected adults from the NA-ACCORD to the general population using ESRD rates from the US Renal Database System (USRDS).

Read the full article here.

Turning Surveillance into Support for Men Who Have Sex with Men in Africa

(AIDSmap) Gus Cairns

We need to stop simply doing research into the health and behaviours of gay men and other men who have sex with men (MSM) in resource-poorer countries, and start using research programmes as springboards for programmes of education and support for them. This was the broad consensus from an audience discussion after a session on MSM at the first day of the 7th International AIDS Society conference (IAS 2013) in Kuala Lumpur, Malaysia.

The discussion was sparked by a presentation from Stefan Baral of Johns Hopkins University on a pioneering project for MSM in Blantyre, Malawi, that did just that.

Dr Baral at first outlined the challenges facing MSM globally and for those who research their needs. HIV prevalence in MSM worldwide is at least as high as it is in heterosexual people in sub-Saharan Africa: regionally, it ranges from 3% in the Middle East to 25% in the Caribbean. In Africa, sporadic studies have found prevalence ranging from 9% in Sudan to no less than 40% in Malawi itself.

HIV incidence studies have only been done rarely in Africa, but found 5% incidence a year in Cape Town, and the extremely high figure of 10% in Nairobi. As for major studies of HIV prevention interventions, not one has been done in the whole of Africa, apart from a single site of the iPrEx pre-exposure prophylaxis study, in Cape Town.

The problem in even finding out data on MSM in Africa, let alone providing effective prevention support, is the extremely hostile climate MSM have to live under in most of the continent. Even in South Africa, community opinion remains homophobic, despite a liberal legal climate.

Besides this, it is intrinsically difficult to get an accurate picture of the true health situation of MSM because it is unfeasible in most situations to interview whole communities and sift out the MSM among them. We therefore have to rely on convenience sampling of various kinds, including respondent-driven sampling (RDS), where initial ‘seed’ community members are recruited and then refer other members of their sexual and friendship network to the researchers. This, of course, may not give a true picture of the generality of MSM, as it may miss out the more isolated or closeted men. In addition, even RDS can only in itself provide health and behavioural data: it is not a method of providing support or education.

To attempt to address this issue and turn RDS into an ongoing programme of support, the Johns Hopkins researchers initially contacted 330 MSM for health and behavioural surveillance. They then offered an ongoing programme of health monitoring, education and support to 100 of the HIV-negative men. This programme included the training of ten peer educators. By the end of the programme, the researchers were able to point out, the research site had become established as an ongoing HIV prevention and education centre for MSM.

The 330-strong baseline group were all over 18 years old and had had anal sex with another man in the last year. One in eight (12.5%) turned out to have HIV and were referred to the HIV clinic for support. Of these, 90% were not aware of the fact, despite 60% having tested for HIV at least once and 34% in the last year. Five per cent had syphilis.

Only 23% said they had ever received HIV prevention information specifically for MSM, and this was reflected in the fact that a majority (58%) thought that vaginal sex posed a higher HIV transmission risk than anal sex, and only 14% thought anal sex more risky than vaginal.

One hundred of the 289 HIV-negative men were retained in a follow-up cohort who were studied for a year. Criteria for belonging to the follow-up group included that they were HIV negative, planned to stay in Blantyre for the next year, and were willing to give a mobile phone number and pseudonym for contact. Instead of just asking them to return to the centre periodically (which they did, for five scheduled appointments during the year), they trained ten peer support workers (not all MSM) who undertook to support the prevention needs of ten members of the follow-up group apiece. These peer support workers received a monthly stipend and as well as providing HIV education and condoms to their group, took part in a programme of training for local doctors and nurses in the health, mental health and HIV prevention needs of MSM.

HIV incidence in the follow-up group was 7%; the study was not designed to assess whether this was lower than baseline incidence. Retention in the study was almost perfect: only one person in the 100-strong group dropped out of the study during the year.

The session featured other studies of gay men around the world. As audience member Steve Mills of the global health group FHI 360 commented, they were all cross-sectional rather than longitudinal studies with the exception of the Malawi one, unearthing data on the situation of MSM but not acting as an intervention themselves, apart from using the survey to provide one-off information and counselling.

Read the complete article here.

New HIV Treatment Guidelines to Cut Millions of Deaths

(Medscape)

KUALA LUMPUR, Malaysia — The World Health Organization has unveiled its much-anticipated new HIV treatment guidelines. Officials say the new approach will prevent 3 million deaths by 2025 and will stop 3.5 million new infections.

“The WHO estimates that these new guidelines will have an unprecedented impact,” director-general Margaret Chan, MD, told a packed room here at the 7th International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention.

An estimated 17 million people are eligible to take antiretroviral drugs, but under the new recommendations this number will increase to 26 million.

The approach reflects the growing body of evidence that treating patients earlier at higher CD4 cell counts, when immune systems are still largely intact, can greatly reduce mortality and prevent HIV transmission.

“Prior WHO guidelines had been for treatment at much later stages of disease,” IAS president-elect Chris Beyrer, MD, professor and associate director for public health, Johns Hopkins Center for Global Health, Baltimore, Maryland, toldMedscape Medical News. “These revisions are based on our new understanding that earlier treatment can have a huge impact on the clinical care of the patient,” he said. “It also turns out that it has a big impact on reducing tuberculosis morbidity and mortality, which is very important in the Asia-Pacific region and Africa.”

The other critical improvement with these new recommendations, said Dr. Beyrer, is the reduction in HIV transmission. “This is a very important announcement, really. WHO guidelines play a normative roll — they’re paid attention to by global ministers of health, and that really matters.”

The new guidelines recommend starting antiretroviral therapy in all patients with a CD4 cell count of 500 cells/mm² or less. Other people should be started on antiretrovirals right away — regardless of CD4 counts — such as HIV-positive serodiscordant couples, patients with hepatitis-B coinfection, women pregnant or breast-feeding, and children younger than 5 years of age.

Read the complete article here.

Malaysia Meeting at ‘Exciting Time for HIV’

(Medpage)

KUALA LUMPUR — The 2013 meeting of the International AIDS Society, here in Malaysia, comes at an “exciting time for HIV science,” according to society president Francoise Barre-Sinoussi, PhD.

The meeting, held in the years between the biennial International AIDS Conferences, focuses on the science needed to combat the pandemic — basic, clinical, prevention, and implementation research.

This year, Barre-Sinoussi told reporters in a telephone briefing, a central focus will be on early treatment of HIV with antiretroviral drugs.

That because evidence has been mounting that early treatment has a cascade of benefits: better health for patients, a lower risk of transmission, and — intriguingly — the possibility of a cure.

“Cure is one of the priorities of the IAS,” Barre-Sinoussi said, and the conference will hear more details of two important studies that seem to show that very early treatment can lead to cure.

In the first, a baby born to an HIV-positive mother was given antiretroviral therapy within an hour of birth, after tests showed she carried the virus.

Mother and daughter fell off the radar screen and their treatment lapsed, but — as reported earlier this year — when physicians next saw the baby, she had no sign of HIV infection.

Investigator Deborah Persaud, MD, of Johns Hopkins University School of Medicine is to give a more detailed report in an invited lecture on July 3.

Read the full article here

Getting Men to Want to Use Condoms (NYTimes)

It takes just a peek at the online store Condomania to appreciate the variety of condoms out there.

Flavors like island punch, banana split and bubble gum. Vibrating condom rings with batteries that last up to 20 minutes. Glow-in-the-dark condoms promising “30 minutes of glowing fun.”

And under the category “Celebrity Condoms,” there is the “Obama Condoms Stimulus Package,” each condom embossed with an image of the president giving two thumbs up.

But even if that presidential seal of approval were real, it would not overcome a chronic and serious public health obstacle: Most men do not like condoms.

Now an influential player in global health, the Bill and Melinda Gates Foundation, is getting into the game. The foundation just finished collecting applications for what it calls a Grand Challenge: to develop “a next-generation condom that significantly preserves or enhances pleasure.”

The goal is to address two significant problems: unintended pregnancies and sexually transmitted diseases like AIDS. Condoms cheaply and effectively prevent both, but around the world only 5 percent of men wear them and there are 2.5 million new H.I.V. infections a year. To stem that tide, health experts say, the number of men regularly using condoms needs to double.

“Decreased sexual pleasure is typically the predominant reason for not using them,” said Stephen Ward, a program officer for the Gates Foundation. “Can we actually make them more desirable? That’s what we’re shooting for.”

Read the complete article here.

Panel supports hepatitis C screening for baby boomers

(NATURE)

A US government advisory panel today recommended  that individuals born between 1945 and 1965 be screened for the hepatitis C virus. The announcement, which strengthens the panel’s earlier advice, increases the likelihood that health-care payers, including Medicaid, will cover screening costs for baby boomers, and that physicians will follow the guidance.

The US Preventive Services Task Force (USPSTF), a group of health experts assembled by the US Department of Health and Human Services,  had before only weakly endorsed generational screening. In adraft recommendation released in November, the USPSTF said that screening the country’s more than 72 million baby boomers would generate a marginal net health benefit, grading the recommendation a  ‘C.’ Since many health-care payers follow only recommendations dubbed B or higher by the panel, experts wereconcerned that physicians would not implement hepatitis C screening for baby boomers.

But in its final statement, the USPSTF upgraded that recommendation to a B.  Acknowledging that not all people who test positive for hepatitis C will develop disease, and treatments often have significant side effects, the panel said that new studies helped make the case that generation-wide screening would be substantially beneficial.

“This is a rapidly moving field and the treatments are always advancing,” says USPSTF panel member Kirsten Bibbins-Domingo, an epidemiologist at the University of California, San Francisco.

The move aligns the USPSTF with the US Centers for Disease Control and Prevention, which in August unequivocally recommended that people  between the ages of 48 and 68 years old be tested for the blood-borne virus, which causes liver disease and cancer. Experts estimate that about 4 million people in the United States are infected with hepatitis C, and  three-quarters of those infected are members of the baby-boom generation — possibly owing to intravenous drug use or past transfusions of unscreened blood.

Overall, up to 75% of those infected with hepatitis C may be unaware of their status owing to the slow onset of diseases caused by the virus. Proponents of routine testing for US baby boomers have argued that the cheap, non-invasive screening could identify more than 800,000 new cases of hepatitis C — which could then be treated using new drugs that are highly effective at eliminating the infection.

David Thomas, a viral-hepatitis specialist at Johns Hopkins University in Baltimore, Maryland, said the USPSTF decision was “a major step forward in the public-health response to hepatitis C infection”. Regardless of what factors influenced the panel’s opinion, “the major message”, says Thomas, “is that we have everyone on board”.

Read the news blog here.

IAS Governing Council: Update on haze condition in Kuala Lumpur

As you may be aware, Kuala Lumpur is currently experiencing increased pollution levels due to forest fires in Indonesia. The below message has been sent to all conference delegates, and the IAS 2013 website will continue to be updated as the situation changes.

Haze in Kuala Lumpur:

We would like to reassure all delegates that IAS 2013 is taking place as planned. The city of Kuala Lumpur is functioning as usual and no flights are currently cancelled by the pollution. The convention centre has a modern air conditioning system. In addition, most hotels are located nearby and many have undercover air conditioned walkways taking them to the area of the convention centre.

However, as a precaution and for your comfort, masks will be available for free in the registration area, for the delegates wishing to go outside.

 

We advise delegates with previous respiratory problems to consult their doctor before travelling to Kuala Lumpur.

We look forward to welcoming you to Malaysia for what we know will be an exciting conference with the latest HIV science, research and news.