Correlates of methadone client retention: A prospective cohort study in Guizhou
province, China

Differing Pattern of HIV-Associated Cancers Seen in India

By C. Vidya Shankar, MD

CHENNAI, India (Reuters Health) Apr 03 - The spectrum of AIDS-
defining and non-defining cancers in HIV patients is different in
India as compared to the west, according to the results of a study
published in the March issue of Cancer Causes & Control.

The paucity of data from India on HIV-associated cancers prompted Dr.
Aruna Dhir and her team from the Tata Memorial Hospital, Mumbai to
examine the distribution of disease among 251 HIV-positive cancer
patients treated in their hospital between 2001 and 2005.

The proportional incidence ratio (PIR), a measure of the excess
incidence of cancers among HIV-infected patients as compared to
reference standards, was calculated for the various cancers.

Unlike in the Western countries, there were no patients with Kaposi's
sarcoma in their series, Dr. Dhir and her colleagues report. Non-
Hodgkin's lymphoma and cervical cancer among AIDS-defining cancers
and cancers of testes, vagina, colon, anal canal, head and neck among
non-AIDS-defining cancers were more common among HIV-positive
patients.

The incidence of breast cancer was not higher among HIV-positive
patients, they add.

Specifically, among the 110 patients with AIDS-defining cancers, the
PIR for non-Hodgkin's lymphoma was 17.1 and 10.3 among males and
females respectively, while the PIR for cervical cancer was 4.1, the
researchers observed.

Access to antiretrovirals may explain the lower incidence of non-
Hodgkin's lymphoma in the USA, they explain.

Unlike in the United States, the prevalence of non-AIDS-defining
cancers was greater than the AIDS-defining cancers, the researchers
note, and a majority of the 141 patients with non-AIDS-defining
cancers were not immunosuppressed. "Lifestyle habits and coinfections
with viruses like human papilloma virus may play a more important
role in the development of non-AIDS-defining cancers than HIV-induced
immune suppression," Dr. Dhir's team postulates.

As for the absence of Kaposi's sarcoma, "The Indian population
probably has a low prevalence of HHV-8," Dr. Dhir told Reuters
Health, "thus explaining the low incidence of Kaposi's sarcoma in our
patients with HIV."

When asked about the need for universal cancer screening of HIV-
infected individuals, Dr. Dhir said, "The screening of cancer in
HIV/AIDS patients is not justified based on the current data."

However, the role of selective screening for cervical cancer and use
of the human papilloma virus vaccine among HIV-positive women needs
further evaluation, the researchers conclude.

Cancer Causes Control 2008;19:147-153.
http://www.medscape.com/viewarticle/572497

Implications Of The New HIV Estimate For India

ScienceDaily (Dec. 4, 2007) — The 2007 UNAIDS/WHO AIDS epidemic
update recently released has revised the global estimate of HIV/AIDS
primarily due to a major reduction of the estimate for India to 2.5
million people living with HIV/AIDS, which is less than half of the
previous official estimate of 5.7 million people. This revision is
based on new population-based data from the National Family Health
Survey in India.
________________________________________

A commentary published in the Lancet on World AIDS Day by health
research experts at The George Institute India, explains the basis of
this drop and the implications for future planning of HIV/AIDS
control in India. Author Professor Lalit Dandona, Senior Director of
The George Institute India and Chair of International Public Health
at The University of Sydney School of Public Health, said today, "The
data from the recent National Family Health Survey support the
findings from similar studies we conducted in southern India, where
we showed that the previously used official method for estimation of
HIV burden in India was in fact not valid, and led to a 2•5 times
higher estimate than what is actually the case."

Professor Dandona explains that well-designed scientific population-
based surveys provide a more reliable representation of HIV in India,
compared to the official method used so far, which extrapolated data
directly from large public-sector hospitals to the population. "The
official method overestimated the burden of HIV in India as the
profile of patients visiting large public-sector hospitals is quite
different from the population at large, in terms of disease
distribution including HIV," he said.

Professor Dandona believes that the new and much reduced HIV estimate
for India has several implications. "We can now see that the official
method for annual estimation of HIV prevalence in India needs
revision. The new figures show the projected number of people needing
HIV treatment over the next decade, and the associated resources
needed, will be less than previously anticipated."

Importantly, the new HIV estimate for India indicates that HIV rates
as seen in sub-Saharan Africa will not occur in India, says Professor
Dandona. HIV prevention efforts in India should therefore be targeted
directly at high-risk groups, such as sex workers, men who have sex
with men, mobile populations (migrant labourers and truckers), people
with other sexually transmitted infections, and injection drug users.
Other areas of focus should include counselling, testing, prevention
of transmission from mother to child, and blood-transfusion safety.

In addition, Professor Dandona says the public-health approach for
HIV control in India needs to become more scientific. "The
establishment of a reliable estimate of HIV burden in India is only
an initial step, what's needed now is more scientific effort to
understand the dynamics of HIV spread in India and the impact of
interventions on HIV control in India," he said.

New AIDS map shows hot zones spread over 20 states, 163 dists

Toufiq Rashid, Posted online:  November 28, 2006 at 0000 hrs

DISTRICTWISE BREAKUP: Delhi, Bihar, Haryana, UP among new entrants

NEW DELHI, NOVEMBER 27: Contrary to conventional wisdom that high
prevalence of HIV/AIDS is restricted to southern states and some
places in the North-East, a new classification done by the National
AIDS Control Programme (NACO) shows that the disease is spread across
as many as 20 states in 163 districts.

These 163 districts have been categorised as "A districts" in the
third phase of the NACO Programme beginning April 1, 2007: districts
where more than 1% of the general population and more than 5% of the
high-risk group is infected with the virus. Experts say this means
these districts have crossed the "epidemic threshold" for the
disease.

While the highest number of these A districts are, predictably, in
states like Andhra Pradesh (21 of 25 districts fall in this
category), Karnataka (24 of 27), Maharashtra (30 of 36), the surprise
entrants are: New Delhi; eight districts in Bihar (including Purnia,
West & East Champaran, Muzaffarpur, Sitamarhi and Kishanganj); five
in Uttar Pradesh (Etah, Etawah, Latehar, Banda and Balrampur); five
in Madhya Pradesh, including Jabalpur and Bhopal; Chandigarh,
Ludhiana and Amritsar in Punjab, Jhalawar and Ganganagar in Rajasthan
and Jhajjar in Haryana.

Sikkim, Tripura, Arunachal Pradesh, Himachal Pradesh, Jammu and
Kashmir, Meghalaya, Jharkhand, Andaman and Nicobar Islands and Assam
are the only states which don't have "A districts."

"The classification of the 611 districts is made on the basis of
epidemiology risk and vulnerability and is based on annual sentinel
surveillance. We will follow this classification for making
districtwise prevention and control programmes,'' said Sujatha Rao,
NACO's Director General.

According to the new classification, instead of having one AIDS
control programme for all states, NACO has estimated districtwise
prevalence to finetune strategies. So while A districts are the hot
zone, 59 fall in the B category: those with less than 1% prevalence
in general population and 5% in high-risk groups.

Category C, with 278 districts, has less than 1% prevalence in
general population and less than 5% in the high-risk group.

D category districts are "the safe districts" where prevalence in the
general population is 0.25% — 111 fall in this category.

"Now that we know the vulnerability and actual problem in the
district, each of the 611 districts in the country will have a link
worker for HIV who will be responsible for implementing the programme
at the district level,'' said Rao.

Source: http://www.indianexpress.com/story/17446.html

Pune: 2nd phase of AIDS vaccine trials halted
22 Nov 2007, 0332 hrs IST , TNN

PUNE: Plans for the second phase human trials of an AIDS vaccine
candidate at the National AIDS Research Institute (Nari) here have
been finally dropped because the vaccine candidate — tgAAC09
(recombinant adeno-associated virus vector) — has not been able to
induce the desired immune response.

The deputy director at Nari, and principal investigator of the phase
I clinical trials, Dr Sanjay Mehendale, told TOI that the decision to
drop plans for the next phase of clinical trials was based on the
cumulative results on the immunogenecity capacity of the vaccine
candidate from the three trial sites — Pune, Germany and Belgium.

"Although the vaccine was well tolerated by the volunteers and no
safety concerns were identified, it was not enough to proceed on to
the next phase of clinical trials, which would involve a much bigger
group of volunteers," he said. "Only 20% of the volunteers at the
three sites responded positively."

The phase I clinical trials for the AIDS vaccine began on February 8,
2005 at Nari. In February this year, Nari scientists announced that
the "whole exercise went off smoothly without any safety concern."

The trials were aimed at evaluating the safety and tolerability of
the vaccine at escalating dose levels as well as immune responses in
healthy adult volunteers not infected by HIV.

Thirty healthy adult volunteers, who had enrolled for the ambitious
programme, were administered with the injectible vaccine called
tgAAC09 (recombinant adenoassociated virus (AAV) vector, expressing
HIV-1 subtype C genes.

The vaccine candidate was developed by Pune researcher Dr Pervin
Anklesaria at the Seattle-based Targeted Genetics Corporation, a
biotechnology company developing gene therapy products for the
treatment of acquired and inherited diseases, and Columbus Children's
Research Institute in partnership with IAVI (International AIDS
Vaccine Initiative).

A senior official from the Indian Council of Medical Research (ICMR),
who attended the planning meeting on September 12 in New Delhi to
discuss the trials, told TOI the decision was taken after analysing
the results of the phase I clinical trials. Similar results on the
immune response have been reported from Belgium and Germany," the
official said.

Although disappointed, Nari scientists said the conduct of the first
ever phase I trials in India was itself a big achievement. We are now
eagerly awaiting the results of a similar phase I human trials —
currently under way at the Tuberculosis Research Centre (TRC) in
Chennai — with another vaccine candidate, the Modified Vaccinia
Ankara (MVA), they said.

Female condoms: Shifting the burden of safe sex to women?

By Rashme Sehgal

Hindustan Latex is all set to market the female condom, particularly
to sex workers. NACO is partnering with 61 NGOs across six states to
reach out to 60,000 female sex workers. Sex workers in Hyderabad,
where the condom was tested, say it gives them a sense of control
over their bodies

The onus of responsibility for safe sexual behaviour has now shifted
squarely onto the shoulders of women. NACO (National Aids Control
Organisation) and the Hindustan Latex Family Planning Promotion Trust
(HLFPPT) have joined hands to promote the female condom as an
alternative to the male condom, especially since there are
innumerable cases being cited by housewives, sex workers and single
women of male partners refusing to use condoms.

Hindustan Latex Ltd (HLL), a State-owned condom manufacturing
company, is all set to market a female condom called `Confidom
passion rings'. The 17 cm female condom is the same size as a male
condom, but two flexible rings at both ends give it the appearance of
a "basketball net". That is how it was described by a sex worker in
Hyderabad, who when she first saw it complained that the polyurethane
condom with its large, lubricated pouch that is fixed to the vagina
seemed much "too big and unwieldy". Once the women were shown how it
worked, however, they realised that it was not as difficult to use as
it appeared.

Sex workers in Hyderabad, amongst whom the female condom was
extensively tested, know that using it is their safest bet to prevent
getting HIV/AIDS or sexually transmitted infections (STIs).
Lakshmiamma, a sex worker, feels safe when she uses a female
condom. "There are no more needless arguments with clients about
using condoms. I have just learnt to protect myself," she says.

In 2006, HLFPPT, the Chicago-based Female Health Company (FHC) and
NACO carried out a social acceptability study on the use of condoms
in Andhra Pradesh, Kerala and Maharashtra, among three sets of target
groups namely female sex workers, men who have sex with men (MSM) and
eligible couples. The total sample size of users was 717, of which
337 were female sex workers.

The objective of the study, which was spread over a period of two
months in 2006, was to analyse perceptions and initial acceptability
of the female condom in terms of efficacy, reliability and ease of
use. It was important also to identify enabling factors affecting
initiation and negotiation, and to find out whether the condom helped
foster communication between partners.

Some sex workers who were part of the sample study spoke candidly
about their experiences with the female condom.

Pushpamma, who works in the old city of Hyderabad, pointed out that
she was happy to use it because it helped protect her from HIV/AIDS.
She said: "The main reason for using a female condom is disease-
prevention rather than as a means of contraception."

Rosy, another sex worker, felt the female condom has several features
in its favour. "Some clients felt its lubrication helped enhance
pleasure. It also provided an effective barrier against drunken
clients who refused to use condoms."

Married women responded in much the same way. The female condom, they
said, was an alternative when their husbands refused to use condoms.
But a Delhi-based teacher felt that the large size of the condom and
the hardness of its inner ring caused too much discomfort during
insertion.

Kavita Patturi, NACO's national programme manager, admits that use of
the female condom between eligible couples dropped from 94% to 89%
during the final week of the survey, while for MSM it dropped to 94%
in the eighth week. Problems cited in using it included its large
size, slippery nature, and the fact that privacy was required in
order to insert it.

"Regular and timely counselling on potential problems is a must in
order to ensure regular usage," says Patturi who admits that wherever
outreach workers were able to provide effective interventions,
barriers such as discomfort and pain were easily overcome.

But the majority of women covered under the study said they were
willing to use the product as it was seen as being woman-initiated
and would lead to their empowerment. Many MSM had even switched to
the female condom because of its reliability. Unlike the male condom,
it does not tear easily, thereby increasing safety.

G Manoj, CEO of the Hindustan Latex Family Planning Promotion Trust,
says: "Women have to be taught how to use it. Demonstrations on its
use were first conducted on vagina moulds by outreach workers
associated with different NGOs working in the area of HIV/AIDS.
Female condoms can succeed only as part of a social marketing
campaign, not if they are sold as mere condoms. This has been the
experience around the globe."

The female condom does have its drawbacks however. It requires time
and privacy to insert, and these are not always available to a sex
worker. But Jayamma, who has helped 1,500 sex workers come together
to form a Hyderabad-based cooperative called Chaitanya Mahila Mandal,
says: "Prior to the female condom we used to be stigmatised for
spreading HIV. That situation has now changed." A government study
has shown that 14% of India's 5.1 million HIV-positive people are sex
workers; female condoms are aimed specifically at them.

Female condoms were introduced in India after two years of research
and test-marketing. Confidoms are being given to NGOs for Rs 3; they
are then sold to sex workers for Rs 5. Although the price is higher
than that of a male condom, female respondents of the survey said
they did not mind spending more because of its reliability.

Jayamma said: "If we can spend money every day on biryani and a
gajra, we can also spend on a female condom."

Patturi says NACO is partnering with 61 NGOs across six states in
order to reach out to 60,000 female sex workers. NGOs with whom
partnerships have been forged include SAATHI, Sapid, Vimochana,
Changes, Jawahar, KAWW, RCTC, SARANG, Sex Workers Forum, Saheli,
Sambhavan, Udaan, Vijay Krida Mandal and Yuvak Pratishtan. "So far we
have not come across a single case of a customer rejecting a sex
worker because she is using a female condom," Patturi points out.

The female condom is not expected to replace the male condom.
Presently, the male condom programme in India extends to over 1.5
billion male condoms. NACO imported 500,000 female condoms in 2006;
the figure has gone up to 1.5-2 million pieces in 2007-08.

"We would like to adopt a cafeteria approach to contraception, with
the male and female condoms playing complementary roles," says Manoj.

The Indian market holds the key to the success of the female condom.
HLL is presently in talks with FHC for transfer of technology to
indigenise production of the female condom to help bring down the
retail price.

 

GF Round 7. India to receive U$88,173,118

(AIeF) Today, during the first day of its fourteenth board meeting
held in Kunming, China, the Global Fund board approved U$$88,173,118
for National AIDS Control Organization (NACO) proposal
for "Strengthening human and institutional capacities of the National
Health System to enable accelerated implementation of the National
AIDS Control Program".

This funding would enable NACO to train 90,000 Nurses (through 55 institutions) and, 12,000 counsellors (through 40 institutes). The program would also target 121 districts, and employ 5300 link workers, covering 12100 villages and 121 million people.

The Global Fund approved the NACO proposal provisionally, subject to
the required clarifications being provided within a limited timeframe
(6 weeks for the applicant to provide an initial detailed response to
the TRP queries, and a further 3 months to obtain the final TRP
approval should further clarifications be requested). The primary
reviewer and secondary reviewer as well as TRP Chair and /or Vice-
Chair need to give final approval of the proposal.

Married Thais form 40% of HIV infected
11 Oct 2007, 1211 hrs IST , AFP
BANGKOK: Married people accounted for more than 40 per cent of all new cases of HIV/AIDS in Thailand last year, the country's health ministry said on Thursday, despite an overall decrease in infections.

About 7,000 married people reported that they had HIV/AIDS in 2006, from a total of 17,000 new cases, according to the latest survey by the ministry's disease control department.

Fourty per cent of new infections in married couples were reported by wives who said they got the disease from their husbands, the survey said, while 10 per cent of the cases were husbands who were infected by their wives.

Extra-marital affairs and men having sex with prostitutes accounted for the rest of the infections.

The survey also said that condom use among couples in 2005 was at a very low level of around 44 to 52 per cent.

But overall new infections reported in 2006 were down from 18,000 in 2005. "Despite the decrease of overall new infections, there are some signs that the AIDS problem in Thailand might get worse again," said Thawat Suntrajarn, the department's director-general.

He called the spike in infections among married couples "worrisome". Thawat said the ministry hoped to see the number of infections this year drop to 14,000 -- just 10 per cent of the 140,000 reported in 1987.

HIV/AIDS is one of Thailand's top causes of death, with some 500,000 Thais living with the disease, according to health ministry figures.

Thailand's universal HIV/AIDS treatment programme has been hailed as a success in the fight against the disease, largely because of the country's ability to provide antiretroviral drugs to patients.

A 2 year study conducted  at All India Institute of Medical Sciences, New Delhi (AIIMS) has found a high rate of extensively drug resistant (XDR) tuberculosis in Indian AIDS patients.  54 full blown AIDS patients suspected of carrying HIV-TBb coinfection  were examined for XDR Mycobacterium TB. The term “extensively drug – resistant coined by doctors defines the state of TB in which the infecting Mycobacterium tuberculosis strain develops resistance to two main first-line drugs – isoniazed and rifampicin  and is also resistant to either one of the three second-line drugs – capreomycin, kanamycin and amikacin.
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Around 13,008 patients at AIIMS were suspected with TB in the hospital based study conducted in 2006.  Out of 13,008 patients, 54 patients were co-infected HIV-TB.  Out of the 54 patients, Mycobacterium TB, leading cause of TB was isolated from 24.  Twelve patients were resistant to first-line drugs and four were also resistant to second line drugs.  All four patients, in whom XDR Mycobacterium TB was isolated, died within 26 months of the diagnosis, the study pointed out. The research carried out by Sarman Singh, Head of the Divisionof Clinical Microbiology, AIIMS along with Dr. M.M> Sankar and K. Gopinath has been accepted by the Journal of AIDS and will be published in November, 2007.
IE 11/11

AIDS cases show a drop
12 Oct 2007, 0225 hrs IST , Kounteya Sinha , TNN
 
NEW DELHI: The number of people infected with the AIDS virus in India continues to nose dive. In July, the National AIDS Control Organisation (NACO) put the prevalence at 0.36% of the population.

On Thursday, the National Family and Health Survey-III, which tested blood samples of 1,00,000 women and men in age group of 15-49 for HIV, put the prevalence rate at 0.28%. This was the second time such a large scale community-based survey to estimate HIV prevalence was carried out in the world. Earlier, only Cambodia had managed such a feat, but the number was obviously much smaller.

Till July 2007, it was estimated that the prevalence of HIV in the general population was 0.9%. After NACO’s announcement in July, India became the third worst affected country with the deadly disease after South Africa (5.5 million) and Nigeria (2.9 million).

NFHS-III has also found that men have higher prevalence rate with 0.36% than women with 0.22%. For both men and women, the prevalence was highest in the 30-34 year age group.

Cities recorded a 40% more HIV prevalence than rural areas. In Tamil Nadu, the prevalence rate is higher among women, while across the country it is higher among men than women. The infection rates varied from 1.13% in Manipur, 0.97% in Andhra, 0.34% in TN, and 0.07% in UP.

Awareness of AIDS was also found to be high — 61% of women and 84% of men of 15-49 years had heard of AIDS. At least 7 out of 10 men know each of the ABC prevention methods — abstinence, being faithful and condoms — as compared to only 4 in 10 women.

Promising Prevention Interventions Perform Poorly in Trials, in Science, Vol 317, 27 July 2007. to view article click here

6. Epidemiology faces its limits – all over again

September 2007

Epidemiologists who are not entirely newcomers to the discipline will remember the debate G Taubes activated by his Science paper in 1995 ‘epidemiology faces its limits’. Now he is back with a paper written to a much larger audience called ‘do we really know what makes us unhealthy’, published in The New York Times, September 16, 2007.

The history this time is about hormone use and menopause, sometimes misleadingly called hormonal replacement therapy (HRT), as if a reduction in estrogen level after menopause is a mistake made by nature that has to be replaced (corrected). Taubes is right that the general wisdom among many clinicians was that these drugs were beneficial for older women in reducing their risk of heart diseases and osteoporosis. He fails to tell that many epidemiologists, however, remained sceptical. Most epidemiologists recalled from their basic training the discussion from the 1970s between epidemiologists from Yale and Harvard on how much use of estrogen increased the risk of endometrial cancer. Estimates from the Yale group were much lower but based upon a flawed design, failing to estimate the exposure distribution in the source population that gave rise to the cases.

Taubes blames the epidemiologists for leading the public astray when they published the data from the large cohort study in 1985 (nurses’ health study) showing that women who used HRT had only one third of the heart attacks found in women who never used HRT. This wisdom was seriously questioned when a randomized trial called HERS found the opposite and these results were further substantiated when the ‘Women’s Health Initiative Trial’ in 2002 also found that use of HRT was a cardiovascular health risk for postmenopausal women.

At the time that the apparent protective effect of HRT was being promoted, other epidemiologists drew attention to the fact that taking HRT also appeared to protect women from suicide and other external causes of death such as homicide. This lack of specificity of effect was a clear signal that the cardioprotective effect of HRT was likely due to confounding. Unfortunately this information was ignored.

Taubes apparently holds the belief that epidemiology is a purely observational science: epidemiologists generated a problem using observational methods that may have killed thousands of women and the problem was corrected by non-epidemiologists. But epidemiology is not defined by its methods but by its research aims. The randomized trial is also one of the methods epidemiologists use to test causal hypotheses and those who did the randomized trials performed epidemiological studies. The problem may have been generated by epidemiologists and was corrected by epidemiologists - making mistakes are not unusual in any scientific discipline. Taubes is right in saying that the health consequences of our flawed research findings can be serious.

Let’s hope for the time being that the trial got it right but it is wise to remember that they have shortcomings as well. Randomization only works well on average in large trials and compliance to the protocol is not a random process making it difficult to estimate effect sizes in an unbiased way. The trial may work well in testing the null hypothesis but we need much more information in health planning and a trial of long duration may be seriously biased by non compliance.

The epidemiologists are usually well aware of the shortcomings of their studies and they were not the strongest advocates of HRT. Epidemiologists know that the evidence they produce may change over time and they know better than others that one should be careful when treating people without a disease. The HRT story is important and should be among the lesson we teach our students.

Jorn Olsen
Shah Ebrahim
Chitr Sitthi-amorn
The IEA Rapid Response Committee