Day: 09/20/2010

HIV among African Americans

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By race/ethnicity, African Americans face the most severe burden of HIV in the United States (US). At the end of 2007, blacks accounted for almost half (46%) of people living with a diagnosis of HIV infection in the 37 states and 5 US dependent areas with long-term, confdential, name-based HIV reporting. In 2006, blacks accounted for nearly half (45%) of new infections in the 50 states and the District of Columbia. Even though new HIV infections among blacks overall have been roughly stable since the early 1990s, compared with members of other races and ethnicities they continue to account for a higher proportion of cases at all stages of HIV—from new infections to deaths.

Estimated Rates of New HIV Infections,
by Race/Ethnicity and Gender, 2006

Estimated Rates of New infections, by Race/Ethnicity and gender, 2006 This a vertical bar graph with six bars. The y-axis represents rates per 100,000 Population. The bar representing Black Men starts at zero and ends at 115.7 and the bar representing Black Women starts at zero and ends at 55.7. The bar representing Hispanic/Latino Men starts at zero and ends at 43.1 and the bar representing Hispanic/Latina Women starts at zero and ends at 14.4. The bar representing White mean starts at zero and ends at 19.6 and the bar representing white women starts at zero and ends at 3.8.

Source: CDC. Subpopulation Estimates from the HIV Incidence Surveillance System—United States, 2006. MMWR. 2008; 57(36):985–989.

The Numbers

New HIV Infections1

  • In 2006, black men accounted for two-thirds of new infections (65%) among all blacks. The rate of new HIV infection for black men was 6 times as high as that of white men, nearly 3 times that of Hispanic/Latino men, and twice that of black women.
  • In 2006, black men who have sex with men (MSM)2 represented 63% of new infections among all black men, and 35% among all MSM. HIV infection rates are higher among black MSM compared to other MSM. More new HIV infections occurred among young black MSM (aged 13–29) than among any other age and racial group of MSM.
  • In 2006, the rate of new HIV infection for black women was nearly 15 times as high as that of white women and nearly 4 times that of Hispanic/Latina women.

HIV and AIDS Diagnoses3 and Deaths

  • Although new HIV infections have remained fairly stable among blacks, from 2005–2008 estimated HIV diagnoses increased approximately 12%. This may be due to increased testing or diagnosis earlier in the course of HIV infection; it may also be due to uncertainty in statistical models.
  • At some point in their lifetimes, 1 in 16 black men will be diagnosed with HIV infection, as will 1 in 30 black women.
  • From 2005–2008, the rate of HIV diagnoses among blacks increased from 68/100,000 persons to 74/100,000. This increase reflectsthe largest increase in rates of HIV diagnoses by race or ethnicity.
  • In 2008, an estimated 18,328 blacks received an AIDS diagnosis, a number that has remained relatively stable since 2005.
  • By the end of 2007, an estimated 233,624 blacks with a diagnosis of AIDS had died in the US and 5 dependent areas. In 2006, HIV was the ninth leading cause of death for all blacks and the third leading cause of death for both black men and black women aged 35–44.

Prevention Challenges

Like other communities, African Americans face a number of challenges that contribute to the higher rates of HIV infection.

Sexual risk behaviors, such as unprotected sex with multiple partners, with a partner who also has other sex partners, or with persons at high risk for HIV infection can be common in some communities.

Injection drug use can facilitate HIV transmission through the sharing of unclean needles. Casual and chronic substance users may be more likely to engage in unprotected sex under the influence of drugsand/or alcohol.

African Americans continue to experience higher rates of sexually transmitted diseases (STDs) than any other race/ethnicity in the US. The presence of certain STDs can significantly increase the chance ofcontracting HIV infection. A person who has both HIV infection and certain STDs has a greater chance of infecting others with HIV.

The socioeconomic issues associated with poverty, including limited access to quality health care, housing, and HIV prevention education, directly and indirectly increase the risk for HIV infection and affect the health of people living with HIV.

Lack of awareness of HIV status. In a recent study of men who have sex with men (MSM) in five cities, 67% of the HIV infected black MSM were unaware of their infection.

Stigma also puts too many African Americans at higher risk. Many at risk for HIV infection fear stigma more than knowing their status, choosing instead to hide their high-risk behavior rather than seek counseling and testing.

What CDC is doing

CDC has initiated a wide range of activities to (1) better understand those factors that drive the HIV and AIDS epidemic among African Americans in the US, (2) expand HIV testing and access to medical care, (3) develop new interventions and scale up the availability of effective interventions, and (4) mobilize African American communities to combat the HIV crisis. Some examples of CDC activities:

  • CDC works closely with state and local health departments and community-based organizations (CBOs) to effectively utilize current HIV prevention interventions proven to be most effective for African Americans.
  • CDC research has led to new interventions that reduce HIV risk in African Americans. CDC continues to identify, develop, and evaluate new behavioral and biomedical interventions for individuals at greatest risk and those living with HIV.
  • CDC is conducting research to better understand and plan interventions to address the social, community, financial,and structural factors that place many African Americans at risk and hinder access to prevention and care.
  • CDC is working with African American leaders from every sector to mobilize communities of color against HIV and deliver culturally appropriate campaigns and messages, including the Act Against AIDS campaign. For more information, visit www.cdc.gov/hiv/aaa.
  • In 2010, CDC announced a second 3-year expanded HIV testing program that supplements an initiative started in 2007 to increase HIV testing among African Americans. CDC is expanding the program to an additional five state, territorial, andmetropolitan health departments. It also broadens the target population to include African Americans and Hispanics/Latinos, as well as MSM and injection drug users of any race/ethnicity. Funding for the program was increased from $36 million to approximately $62 million.

Lopinavir Monotherapy: High Risk for Viral Relapse in the Central Nervous System

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Switching to lopinavir/ritonavir monotherapy was associated with a high failure rate and with elevated viral loads in the cerebrospinal fluid.

Combination antiretroviral therapy has substantially reduced HIV morbidity and mortality, but the adverse effects and cost of multiple drugs remain a concern, prompting interest in treatment simplification. Because of its high resistance barrier, boosted lopinavir has been considered an attractive option for simplified maintenance therapy.

In this open-label trial, researchers randomized 60 patients who had viral loads <50 copies/mL for at least 3 months to either continue their triple-drug therapy or switch to lopinavir/r monotherapy. The primary endpoint was treatment failure in the central nervous system (CNS) and/or genital tract.

The trial was stopped prematurely when 6 of the 29 patients on monotherapy — versus none of the 31 on triple-drug therapy — experienced treatment failure in the blood (defined as 2 consecutive plasma viral loads >400 copies/mL). These failures all occurred within the first 6 months of monotherapy and in patients who had nadir CD4 counts <200 cells/mm3; four of the patients developed neurological symptoms. Five patients underwent lumbar puncture after treatment failure in the blood, and all had elevated HIV RNA levels in the cerebrospinal fluid (CSF). An additional 8 of 25 patients on monotherapy had detectable HIV RNA in the CSF, compared with 0 of 15 on triple-drug therapy.

Comment: Protease inhibitor (PI) monotherapy has been associated with higher levels of low-level viremia and more “blips” than combination therapy. This study, although small, adds an intriguing observation to previous data sets, implicating incomplete suppression of HIV replication in the CNS as a risk of PI monotherapy and a cause of frank failure. Detectable HIV RNA in the CSF was not only an important predictor of failure but was also associated, at least in some patients, with overt neurological disease.


Published in Journal Watch HIV/AIDS Clinical Care September 20, 2010

glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee

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To determine the effect of glucosamine, chondroitin, or the two in combination on joint pain and on radiological progression of disease in osteoarthritis of the hip or knee.

Design Network meta-analysis. Direct comparisons within trials were combined with indirect evidence from other trials by using a Bayesian model that allowed the synthesis of multiple time points.

Main outcome measure Pain intensity. Secondary outcome was change in minimal width of joint space. The minimal clinically important difference between preparations and placebo was prespecified at −0.9 cm on a 10 cm visual analogue scale.

Data sources Electronic databases and conference proceedings from inception to June 2009, expert contact, relevant websites.

Eligibility criteria for selecting studies Large scale randomised controlled trials in more than 200 patients with osteoarthritis of the knee or hip that compared glucosamine, chondroitin, or their combination with placebo or head to head.

Results 10 trials in 3803 patients were included. On a 10 cm visual analogue scale the overall difference in pain intensity compared with placebo was −0.4 cm (95% credible interval −0.7 to −0.1 cm) for glucosamine, −0.3 cm (−0.7 to 0.0 cm) for chondroitin, and −0.5 cm (−0.9 to 0.0 cm) for the combination. For none of the estimates did the 95% credible intervals cross the boundary of the minimal clinically important difference. Industry independent trials showed smaller effects than commercially funded trials (P=0.02 for interaction). The differences in changes in minimal width of joint space were all minute, with 95% credible intervals overlapping zero.

Conclusions Compared with placebo, glucosamine, chondroitin, and their combination do not reduce joint pain or have an impact on narrowing of joint space. Health authorities and health insurers should not cover the costs of these preparations, and new prescriptions to patients who have not received treatment should be discouraged.

source:BMJ

FDA Investigating Potential Link Between Pioglitazone and Bladder Cancer

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Long-term use of pioglitazone (Actos) might be associated with increased risk for bladder cancer, according to an ongoing drug safety review conducted by the FDA.

The agency looked at 5-year data from a planned 10-year observational study evaluating the potential association between pioglitazone and bladder cancer. Among nearly 200,000 adults with diabetes, overall use of the drug was not associated with a statistically significant increase in cancer risk. However, patients using pioglitazone for longer than 2 years had significantly elevated risk, as did those receiving the highest cumulative doses.

The FDA expects to finish its safety review within a few months. For now, it advises providers to continue prescribing pioglitazone according to the label’s instructions, and to report adverse events to the MedWatch program.

Add-On Tiotropium May Help Adults with Asthma

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Adults with asthma who need more than standard inhaled-glucocorticoid therapy may benefit from add-on tiotropium (Spiriva), a long-acting anticholinergic agent, suggests an NIH-funded study of about 200 patients in the New England Journal of Medicine. Tiotropium is currently FDA approved to treat chronic obstructive pulmonary disease.

In the double-blind, placebo-controlled, crossover study, 14 weeks of add-on tiotropium was superior to double-dose glucocorticoid therapy and was noninferior to add-on salmeterol (Serevent, a long-acting beta-agonist) in terms of morning peak expiratory flow and several secondary outcomes, such as number of asthma-control days.

An editorialist welcomes this alternative to long-acting beta-agonists, which have been linked to rare but life-threatening asthma exacerbations. However, he notes that the long-term effectiveness of tiotropium compared with beta-agonists remains unknown, as does its potential for masking underlying airway inflammation.