MRSA Infections Are Now Falling in People With HIV

Researchers in Atlanta report that cases of methicillin-resistant Staphylococcus aureus (MRSA), an aggressive and difficult-to-treat bacterial infection, have dropped considerably since 2007. These data, published March 17 in the journal AIDS, could signal the beginnings of a reversal of a trend of sharp increases in the infection during the past decade, particularly among HIV-positive men who have sex with men (MSM).

MRSA outbreaks generally occur in one of two venues: Health care institutions, such as hospitals, or in the general community. Since the mid-1990s, cases of both health care–associated and community-acquired MRSA have been increasing, and some of the circulating strains have become more virulent and more resistant to antibiotics than their predecessors.

Scientists and health care providers have expressed alarm at the increase in diagnoses of MRSA in people with HIV during the past 10 years, a rise that coincides with—but greatly surpasses—increases in the general population. Their alarm has not only been about the increased spread of the infection, but also about the growing difficulty of treating it among HIV-positive people and about the frequency in which it returns after being treated.

A previous study of nine metropolitan areas in the United States found a drop in cases of health care–associated MRSA in the general population. Intrigued by those findings, Alicia Hidron, MD, and her colleagues from Emory University School of Medicine in Atlanta, set out to assess trends in MRSA diagnoses within HIV-positive participants in an Atlanta Veterans Affairs (VA) medical system cohort.

Of the greater than 3,000 people enrolled in the VA cohort, Hidron’s team gathered data on 226 MRSA community-acquired infections that occurred in 168 HIV-positive people between 2002 and 2009. The majority of the cases, 94 percent, were community-acquired. Among those diagnosed with MRSA—nearly all of whom were black men—the average CD4 count at the time of their MRSA infection was 350. Fifty of the cases occurred in people with CD4s under 50, and 46 cases occurred in people with CD4s over 50 but under 200. Just over half of the cases were among men who have sex with men (MSM), and 14 percent were in injection drug users (IDUs).

MRSA infections were more than twice as likely to occur in MSM and IDUs as in people with other HIV risk factors. People with CD4s under 50 were more than four times as likely to develop MRSA, and those with CD4s between 51 and 200 were about twice as likely to develop the infection. Conversely, people taking antiretroviral (ARV) therapy were nearly three times less likely to develop MRSA.

Hidron’s team found that MRSA cases rose dramatically—more than 17-fold—between 2002 and 2007 but then began falling just as quickly between 2007 and 2009—when cases dropped by about 65 percent.

Though the study could not isolate the causes of the drop in MRSA infections, the authors theorize that several explanations are possible. First, they acknowledge that previous studies have found that changes in sex and drug-using behaviors and networks are often the primary driver of community-acquired MRSA, and that could be a factor here.

They also acknowledge, however, the significant difference in the risk of MRSA in people taking ARVs, compared with those not on treatment, and in people with higher versus lower CD4s. “To our knowledge, this study is the first to suggest that [ARV therapy] may result in a reduced risk of MRSA infections,” they state.

A third explanation may be that if hospital-acquired infections are dropping—as documented in the other study—there may also be a lower overall spread of MRSA in the general population, leading to fewer cases in people with HIV.

The authors are encouraged by the steep drop in MRSA cases among their cohort, but they are calling for further studies to help understand why this occurred.

The Friends of AIDS Foundation is dedicated to enhancing the quality of life for HIV positive individuals and empowering people to make healthy choices to prevent the spread of the HIV virus. To learn more about The Friends of AIDS Foundation, please visit: http://www.friendsofaids.org.


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DOJ Calls on State Attorney Generals to Fight Illegal Exclusion of Individuals with HIV/AIDS

Public and private trade schools for barbering, cosmetology, massage therapy, home health care work and other occupations, as well as state licensing agencies, may be illegally denying individuals with HIV/AIDS admission to trade schools and/or occupational licenses because of their HIV status.

The Justice Department has issued letters to the attorneys general of all 50 states, as well as U.S. territories to request their assistance in addressing the illegal exclusion of individuals with HIV/AIDS from occupational training and state licensing. Persons with HIV and persons with AIDS are covered by the Americans with Disabilities Act (ADA), which gives federal civil rights protections to persons with disabilities in public accommodations, employment, and state and local government services.

The Justice Department has learned that public and private trade schools for barbering, cosmetology, massage therapy, home health care work and other occupations, as well as state licensing agencies, may be illegally denying individuals with HIV/AIDS admission to trade schools and/or occupational licenses because of their HIV status. However, because HIV cannot be transmitted by casual contact or by the circumstances present in these occupations, HIV-positive status is irrelevant.

In his letter to the attorneys general, Assistant Attorney General for the Civil Rights Division Thomas E. Perez asked that they review their respective jurisdictions’ admission and licensing criteria for trade schools and licensing agencies to identify the existence of any criteria that unlawfully exclude or discriminate against persons with HIV/AIDS, and to take the steps necessary to bring all such programs into compliance with the ADA.

“It is critical that we continue to work to eradicate discriminatory and stigmatizing treatment towards individuals with HIV based on unfounded fears and stereotypes,” Assistant Attorney General Perez said. “The ADA clearly protects individuals with HIV and other disabilities from this kind of exclusion or marginalization.”

The department recently entered into a settlement agreement with Modern Hairstyling Institute Inc., a private cosmetology school in Bayamón, Puerto Rico, for delaying the admission of an HIV-positive individual. That settlement agreement requires the school to remove questions about applicants’ HIV/AIDS status and to promptly enroll the aggrieved individual in its cosmetology program. The department has also addressed related issues in its guidance entitled “Questions and Answers: The Americans with Disabilities Act and the Rights of Persons with HIV/AIDS to Obtain Occupational Training and State Licensing”-http://www.ada.gov/qahivaids_license.htm.

The Friends of AIDS Foundation is dedicated to enhancing the quality of life for HIV positive individuals and empowering people to make healthy choices to prevent the spread of the HIV virus. To learn more about The Friends of AIDS Foundation, please visit: http://www.friendsofaids.org.


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Study Shows Importance of Resistance Testing Before Start of HIV Treatment

European research published in the February 28th edition of The Lancet shows the importance of considering the results of tests for transmitted resistance when selecting a patient’s first combination of antiretroviral drugs.

Individuals treated with a regimen which was not completely active were three times more likely to experience virologic failure during the first year of treatment than individuals with no resistance or those who had resistance but were treated with therapies to which the strain of HIV they had was fully susceptible.

There was also some evidence that baseline resistance impaired immune recovery.

“Transmitted drug resistance was associated with virological failure in patients who received at least one drug to which the virus had lost susceptibility,” write the investigators, who say their findings underscore “the need for at least three fully-active antiretroviral drugs to optimise virological response to a first-line regimen.”

In Europe, use of antiretroviral therapy has dramatically improved the prognosis of many patients with HIV. However, expanded use of HIV treatment has been accompanied by an increase in the transmission of drug-resistant HIV. Approximately 10% of all new infections in Europe involve a strain of virus that is resistant to at least one antiretroviral drug.

Resistance is the major reason why anti-HIV drugs cannot control viral load. European and British guidelines recommend that all patients should be tested for drug resistance soon after their diagnosis with HIV and again before they start antiretroviral therapy. First-line HIV therapy should take into account the results of this surveillance.

However, there is uncertainty about the impact of transmitted resistance on responses to first-line HIV treatment. This is especially the case if a patient with resistance takes a fully active combination of drugs.

To gain a better understanding of this issue, European investigators examined outcomes in 10,000 patients who started HIV therapy after 1998. The patients were enrolled in 25 different adult and paediatric cohorts.

All the patients had a resistance test before they started therapy. Changes in viral load and CD4 cell count in the first year of treatment were examined.

The risk of virologic failure (two consecutive viral loads above 500 copies/ml after six months of treatment) was compared between patients according to whether they had no transmitted resistance; resistance, but treated with a combination of drugs that were fully active; or transmitted resistance and treated with a sub-optimal combination.

Approximately 10% of patients had transmitted resistance. Half were treated with antiretrovirals to which their HIV was fully susceptible. The others received therapy to which their HIV was at least partially resistant.

After a year of treatment, 4.2% of patients without transmitted resistance had experienced virologic failure. The rate was marginally higher (4.7%) for individuals with transmitted resistance who received therapy with three fully active drugs. However, a far greater proportion (15%) of patients with resistance and reduced susceptibility to a drug they received experienced virologic failure.

The investigators calculated these patients had a threefold increase in their risk of virologic failure (p < 0.001).

Furthermore, patients with high-level resistance to the drug(s) they were taking had a sixfold increase in their risk of viral load remaining detectable or rebounding after six months of treatment (p < 0.001).

There was some evidence that therapy that included a ritonavir-boosted protease inhibitor was a good option for individuals with resistance who received fully active treatment. They were no more likely to experience virologic failure than individuals with no resistance who received this class of drug.

However, there was weak evidence of a higher risk of treatment failure for patients with transmitted resistance who received fully active treatment based on an NNRTI, compared to individuals with no resistance who were also treated with this class of drug (hazard ratio = 2.0; 95% CI, 0.9-4.7, p = 0.093).

After one year of therapy, the median increase in CD4 cell count was 183 cells/mm3. There was modest evidence that patients with resistance who took therapy which was not fully active had smaller increases in their CD4 cell count during the first month of therapy. This was most apparent among patients who received an NNRTI (p = 0.0514).

“This finding is important because it suggests a poor immunological response in patients with transmitted drug resistance who are started on a suboptimum regimen will result in poorer CD4 response and ultimately risk of disease progression,” write the authors.

They conclude, “this European observational multicohort study confirms present treatment guidelines that state that the initial treatment choice should be based on resistance testing in treatment-naïve patients.” In settings where resistance testing is not available, they suggest that a treatment based on a ritonavir-boosted protease inhibitor “should probably be considered.”

The Friends of AIDS Foundation is dedicated to enhancing the quality of life for HIV positive individuals and empowering people to make healthy choices to prevent the spread of the HIV virus. To learn more about The Friends of AIDS Foundation, please visit: http://www.friendsofaids.org.


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Broadcast Premiere - "Let's Talk About Sex"

LET’S TALK ABOUT SEX presents an innovative and empowering new vision for shifting our approach to young people and sexual health in the United States.

While American teens live in a society that uses sex to sell everything from lipstick to laptops, they are rarely afforded opportunities to discuss sex and sexual health in an open, honest way.

Through interviews with real parents and teens, health experts, and faith leaders, director James Houston presents a revealing look at how American attitudes towards adolescent sexuality impact teenagers. The United States has among the highest teen pregnancy and STD rates in the industrialized world.

LET’S TALK ABOUT SEX is both a catalyst and a tool to initiate healthy conversations in kitchens and classrooms across the country.

Broadcast Premiere

LET’S TALK ABOUT SEX
April 9, 2011 on TLC

Speakers at Forum Debate Condoms in City Schools

At a health forum on March 16, Rochester's school board solicited community feedback in response to a January presentation about sexual activity and HIV cases among area young people.

Of 78 HIV diagnoses reported in Monroe County last year, 35 were in people younger than 25, the board heard during the January presentation. Of teens reporting sexual intercourse, 61 percent used a condom during the last encounter, said Dr. Andrew Doniger, the county health director.

"Another way of looking at that is 39 percent didn't," Doniger said. "That's risky for that 39 percent."

"I know we have a serious issue in our community with [STDs], HIV and AIDS," said Cynthia Elliott, chair of the Community and Intergovernmental Relations Committee, which hosted the forum. "Something has to be done. Is it the school district necessarily? I don't know."

"We really want to hear what the community is saying," said Jose Cruz, chair of the Policy Development and Review Committee. "Will we please everyone? No. But we'll address their concerns and make the best decision possible."

Qualified outside agencies should be allowed to teach about sexuality, and sexually active students should have access to condoms, said Sheila Driscoll, director of Metro Council for Teen Potential.

Parents struggle with how to discuss sex, and the spiritual and emotional aspects of it are often neglected, said the Rev. George Nicholas, pastor of Grace United Methodist Church. "Instead of saying 'Just don't do it,' we need to be open to having a conversation," he said.

Many teens said their peers would continue to have sex in any case, and that making condoms available at schools would give them a trusted place to go. But retired doctor Barbara Fredericks said condoms deny the necessity of self-control, while others said condoms give teens a false sense of safety.

The Friends of AIDS Foundation is dedicated to enhancing the quality of life for HIV positive individuals and empowering people to make healthy choices to prevent the spread of the HIV virus. To learn more about The Friends of AIDS Foundation, please visit: http://www.friendsofaids.org.


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Integrating HIV Care with Broader Maternal and Child Health

In the three years since it integrated routine services with HIV diagnosis and care, the Maternal and Child Healthcare Clinic at Kakamega Provincial General Hospital has seen an 80 percent increase in uptake of its services to prevent mother-to-child HIV transmission. This, observers say, bodes well for similar efforts throughout the nation's health care system, where the walls between routine care and HIV treatment are coming down.

When the Kakamega clinic's services were separated, "Stigma was found to be the major cause of dropouts, since it was common knowledge that anybody being referred to the comprehensive care center was HIV-positive," said Khadija Nalinya, nursing officer in charge.

The dramatic improvement since the integration confirms the results of a Family Health International study conducted in Rwanda. Researchers in that examination of 30 health care centers found that ending the segregation of primary health care and HIV services boosted the uptake of both.

Now Kenya's government is enacting the change across its health care system. Special rooms for counseling and testing, specific pharmacies for people with HIV, and other separate accommodations will be phased out nationwide by the end of next year. So far, three other health care facilities are following in Kakamega's example, said Dr. Sirengo Martin, manager of the Prevention of Mother to Child Transmission (PMTCT) program at the National AIDS/STD Control Program.

"These services will be offered in the same room where MCH [maternal child health] and family planning services are offered," Martin said. "For effective integration, the government is cross-training MCH and HIV service providers so that they can offer antenatal and PMTCT services in the same visit."

In Western Kenya, four public health clinics have taken the process a step further by integrating HIV care with outpatient services.

The Friends of AIDS Foundation is dedicated to enhancing the quality of life for HIV positive individuals and empowering people to make healthy choices to prevent the spread of the HIV virus. To learn more about The Friends of AIDS Foundation, please visit: http://www.friendsofaids.org.


TOGETHER WE REMAIN STRONG!

Mississippi Sex Education Bill Signed

Gov. Haley Barbour has signed into law HB 999, a measure that requires Mississippi public schools to provide sex education.

Previously, the state did not require school districts to teach sex education but those that did had to use an abstinence-only curriculum. Under the new law, districts must begin teaching sex education by the end of June 2012. The state standard will continue to be abstinence-only, though districts can elect to adopt an "abstinence-plus" approach, which covers topics such as contraception.

Districts "must choose one or the other," said Rep. John Mayo (D-Clarksdale). "You're not just going to ignore this problem."

In 2009, the latest year for which data are available, Mississippi led the nation in teenage births. Also that year, CDC's Youth Risk Behavior Survey indicated 61 percent of high school students in the state had engaged in sexual activity - the national average was 46 percent.

HB 999 gives local school boards "the authority to select the policy that they think is right for their community," said state Department of Education spokesperson Wendy Polk. "We will work with each district to provide training and resources to help them with their curriculum." Districts will be required to report which choice they make, allowing the department to study what works.

The law stipulates that students be divided by gender for sex education instruction, forbids condom use demonstrations, and maintains that abortion cannot be included as a means of birth control. Parents will be able to opt their child out of the classes.

Mayo noted that some dissenters have asked what business the state has in teaching children about sex. "The state has a financial responsibility because the health care costs for teenage pregnancies for unwed mothers are enormous," he said.

The Friends of AIDS Foundation is dedicated to enhancing the quality of life for HIV positive individuals and empowering people to make healthy choices to prevent the spread of the HIV virus. To learn more about The Friends of AIDS Foundation, please visit: http://www.friendsofaids.org.


TOGETHER WE REMAIN STRONG!