INDIANA - HIV Epidemic

"Rural Indiana struggles with drug-fueled HIV epidemic" PBS NewsHour 5/1/2015

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SUMMARY:  A rural region of Indiana has become the center of the state's worst-ever HIV epidemic.  For the first time, that state's legislature passed a bill this week allowing drug users in high-risk areas to trade used needles for clean ones.  In collaboration with Kaiser Health News, special correspondent Sarah Varney reports on how health officials, lawmakers and residents are grappling with the crisis.

JUDY WOODRUFF (NewsHour):  In a first for Indiana, the state’s legislature this week passed a bill permitting drug users in areas with health outbreaks to trade used needles for clean ones.  It’s in response to an HIV outbreak of historic proportions.

Sarah Varney has our report from Austin, Indiana, near the Kentucky border.

This story was produced in collaboration with our partner, Kaiser Health News.

WOMAN:  Jesus loves you, you know.

SARAH VARNEY, Kaiser Health News:  Local churches in Austin, Indiana, have taken to the streets to reclaim their neighborhoods from a drug-fueled HIV epidemic that has decimated this all-American town.

Over the last month, this prayer walk has grown from a handful to hundreds.  Austin is a largely white town of some 4,000 people, proud of its country roots and manufacturing plants that have held on despite hard times and growing poverty.  It’s a place where everyone knows everyone else, but few families have escaped drug addiction.

HIV cases had been few and far between in this rural patch of southern Indiana.  But, in January, the number of confirmed cases jumped to 11, then to 40, and now more than 140 people are infected.  It’s the largest HIV outbreak in Indiana’s history and the largest seen in rural America in many years.

Dr. William Cooke is Austin’s only physician.  He says the conditions for an outbreak have been ripe for a decade.

DR. WILLIAM COOKE, Foundations Family Medicine:  We had a high incidence of drug use.  That started off as just painkillers, people sharing their prescriptions with each other, buying prescriptions, that sort of thing.  And then somewhere around 2010, 2011, that took a turn towards I.V. drug use.

SARAH VARNEY:  A prescription painkiller called Opana had been reformulated, and addicts found they now needed to inject it to reach a euphoric high.

DR. WILLIAM COOKE:  In the county, it wasn’t surprising that HIV came in next.

HIV - Getting to Zero?

"How San Francisco plans to ‘get to zero’ new infections of HIV" PBS NewsHour 4/11/2015

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SUMMARY:  An ambitious new plan in San Francisco aims to completely end the transmission of HIV, which infects about 50,000 people every year nationwide.  In a city where huge strides have already been made in battling the epidemic, public health officials, doctors and activists are increasing their efforts to bring the number of new HIV infections down to zero.  NewsHour's John Carlos Frey reports.

JOHN CARLOS FREY (NewsHour):  At Ward 86, a bustling outpatient HIV clinic at San Francisco General Hospital, nurse Diane Jones drops everything when this pager goes off.

It means that someone in the city just tested HIV positive.

DIANE JONES:  So, I’m going to make him an appointment.

Jones is following a protocol called ‘RAPID’ which is designed to get new HIV positive individuals into treatment immediately.

DIANE JONES:  Just got diagnosed today, last negative was June.

JOHN CARLOS FREY:  Jones scrambles to make plans for the new patient who is seen just hours later.

It’s part of an ambitious plan in San Francisco to completely end new HIV infections.

Each year about 50,000 people in the United States are infected with HIV.  And while the disease has moved off the front pages as treatment has made infection more of a manageable chronic condition, an estimated 13,700 people still die from AIDS in the U.S. each year.

Globally, an estimated 1.5 million people are killed.  It’s the 6th leading cause of death.

In San Francisco there are relatively few new HIV infections — 359 in 2013 and overwhelmingly found in gay men.  It’s a number that has been falling over the past eight years.  But new infections haven’t gone away.

Today, public health officials, doctors, and activists are increasing their efforts to bring that number all the way down to zero.

HEALTH - Setback, 'Cured Child' HIV Returns

"HIV rebound in young child is ‘another step’ in long process of AIDS research" PBS NewsHour 7/11/2014

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JEFFREY BROWN (NewsHour):  It was in March of last year that doctors thought they might have made a breakthrough in the goal of finding a cure for AIDS, treating a baby girl in Mississippi with early and unusually aggressive drug therapy.

The mother had HIV and had not been treated during pregnancy.  But the girl was treated within 30 hours of her birth and was free of the virus for two years.  Doctors allowed her to stay off therapy and, still, there were no signs of HIV returning.

But, yesterday, officials announced that the girl, now almost 4, had tested positive for HIV during a follow-up visit last week.

Dr. Anthony Fauci of the National Institute of Allergy and Infectious Diseases joins me now.

And welcome back to you.

This is something that you and I talked about when the news came out last year.  So, remind us first why this seemed so hopeful, how this early and aggressive treatment promised such a difference.

HEALTH - Early Treatment of HIV Infants Works

"Early Treatment Is Found to Clear H.I.V. in a 2nd Baby" by DONALD G. McNEIL Jr., New York Times 3/5/2014

When scientists made the stunning announcement last year that a baby born with H.I.V. had apparently been cured through aggressive drug treatment just 30 hours after birth, there was immediate skepticism that the child had been infected in the first place.

But on Wednesday, the existence of a second such baby was revealed at an AIDS conference here, leaving little doubt that the treatment works.  A leading researcher said there might be five more such cases in Canada and three in South Africa.

And a clinical trial in which up to 60 babies who are born infected will be put on drugs within 48 hours is set to begin soon, another researcher added.

If that trial works — and it will take several years of following the babies to determine whether it has — the protocol for treating all 250,000 babies born infected each year worldwide will no doubt be rewritten.

“This could lead to major changes, for two reasons,” said Dr. Anthony S. Fauci, executive director of the National Institute for Allergy and Infectious Diseases.  “Both for the welfare of the child, and because it is a huge proof of concept that you can cure someone if you can treat them early enough.”

The announcement was the third piece of hopeful news in two days about the virus that causes AIDS.

On Tuesday, scientists reported that injections of long-lasting AIDS drugs fended off infection in monkeys, and on Wednesday, researchers announced a “gene editing” advance that might enable immune cells to repel the virus.

The first infant to make an apparent recovery from H.I.V. infection, now famous as the “Mississippi baby,” was described last March at the Conference on Retroviruses and Opportunistic Infections, the same annual meeting where the new case was reported on Wednesday.

The Mississippi child, now more than 3 years old, is still virus-free, said Dr. Deborah Persaud, a virologist who has run ultrasensitive tests on both children in her lab at the Johns Hopkins Children’s Center in Baltimore.

The second baby, a girl born at Miller Children’s Hospital in Long Beach, Calif., is now 9 months old and apparently free of the virus that causes AIDS.

Her mother, who has advanced AIDS and is mentally ill, arrived in labor; she had been prescribed drugs to protect her baby but had not taken them.

Four hours after the birth, a pediatrician, Dr. Audra Deveikis, drew blood for an H.I.V. test and immediately started the baby on three drugs — AZT, 3TC and nevirapine — at the high doses usually used for treatment of the virus.

The normal preventive regimen for newborns would be lower doses of two drugs; doctors usually do not use the more aggressive treatment until they are sure the baby is infected, and then sometimes not in the first weeks.

“Of course I had worries,” Dr. Deveikis said in an interview here.  “But the mother’s disease was not under control, and I had to weigh the risk of transmission against the toxicity of the meds.”

“I’d heard of the Mississippi baby, I’d watched the video,” she added.  “I knew that if you want to prevent infection, early treatment is critical.”

The Long Beach baby is now in foster care, she said.  The mother is still alive as well.

It is incorrect to describe the baby as “cured” or even as “in remission” because she is still on the drugs, Dr. Persaud said.  But because the most sensitive blood tests can find no virus capable of replicating, she describes the baby as “having sero-reverted to H.I.V.-negative.”

Both DNA and RNA of the virus were found in the baby’s early blood and spinal fluid samples, so Dr. Persaud said it was virtually certain she was infected at birth.  The virus began to disappear six days after birth and was undetectable within 11 days.

It is considered medically unethical to stop the baby’s drugs now, but Dr. Deveikis and Dr. Yvonne J. Bryson, a pediatric AIDS expert at the University of California, Los Angeles, who is also working on the case, said they would consider stopping them briefly to see what happens if the baby is still virus-free at age 2.

Dr. Bryson is one of three investigators who will lead the clinical trial seeking 60 babies.

Obstetricians and pediatricians in the United States, South Africa and Brazil will be alerted to watch for babies being born to mothers who have not taken drugs to prevent mother-child transmission and to get them on full antiretroviral treatment immediately, even before the first blood test has been finished.  (In the United States, fewer than 200 children each year are born with H.I.V.)

The trial will be funded by Dr. Fauci’s institute and be part of the Impact series of trials concentrating on preventing viral transmission to newborns.

“When we described the Mississippi baby, we were met with some skepticism,” she said.  The Long Beach baby “was definitely infected.”

The Mississippi baby was born to a mother who got no prenatal care and was unaware that she was infected.  Worried doctors at a local hospital transferred the baby to the University of Mississippi Medical Center, where a pediatrician, Dr. Hannah B. Gay, started aggressive antiretroviral treatment about 30 hours after birth.

Then, 18 months later, the mother stopped taking the baby to appointments and stopped giving the drugs.  Five months later, when she came to an appointment, doctors feared the baby would be teeming with virus.

Instead, to their astonishment, they found none.  And Dr. Persaud’s testing has found none, despite using tests normally able to detect dormant virus in adult patients on successful treatment.

Although antiretrovirals prevent the virus from replicating, a small amount usually persists in reservoirs throughout the body, integrated into the DNA of cells.  Dr. Persaud’s test can activate those cells and force them to “spit out” the virus, where it can be detected.

Dr. Steven G. Deeks, an AIDS expert at the University of California, San Francisco, said the Long Beach baby offered more convincing evidence that starting therapy virtually at birth seems to kill the virus before it establishes a permanent reservoir.

“But it sure would be nice to have a way to decide when to stop” the treatment, he added.  “That’s the next question.”

HEALTH - AIDS Research, Eliminating the Need For Lifetime of Powerful Pills

"In search of a cure, scientists look for where HIV hides" PBS Newshour 2/7/2014

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JUDY WOODRUFF (Newshour):  The battle against AIDS, which began in the early 1980s and has succeeded in finding treatments to control the disease, is increasingly turning to a different phase: the hunt for a real and complete cure.

Special correspondent Spencer Michels has our story.

SPENCER MICHELS (Newshour):  Fifty-seven-year-old Matt Sharp, who has had AIDS for 25 years, takes a mix of antiretroviral drugs each day to reduce his HIV levels and keep him alive.

Sharp, a former ballet dancer, says the medication has shortened his life, and makes him more susceptible to other ailments, like heart disease earlier than normal.

MATT SHARP:  I’m faced with issues around growing older earlier because of having HIV for so long.  I have been taking pills for over 25 years.  I’m ready for a point where I can do something that my body can control the virus on its own.

SPENCER MICHELS:  Sharp has volunteered for studies now under way that, if successful, could eliminate the need for a lifetime of powerful pills.

Scientists and medical doctors are working both in the lab and in clinical settings to find out more about HIV, especially where it lurks, and to find out how patients will respond to experimental treatments.  The idea, of course, is to completely eradicate the HIV.

HIV - Laws That Provide Disincentive For Testing

"Sex, Lies and HIV:  When What You Don’t Tell Your Partner Is a Crime" by Sergio Hernandez, ProPublica 12/1/2013

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Nick Rhoades was clerking at a Family Video store in Waverly, Iowa, one summer afternoon in 2008 when three armed detectives appeared, escorted him to a local hospital and ordered nurses to draw his blood.  A dozen miles away, his mother and stepfather looked on as local sheriff’s deputies searched their home for drugs — not illegal drugs, but lifesaving prescription medications.

Lab results and a bottle of pills found in the Rhoades’ refrigerator confirmed the detectives’ suspicions: Nick Rhoades was HIV-positive.

Almost a year later, in a Black Hawk County courtroom, Judge Bradley Harris peered down at Rhoades from his bench.

“One thing that makes this case difficult is you don’t look like our usual criminals,” Harris said.  “Often times for the court it is easy to tell when someone is dangerous.  They pull the gun.  They have done an armed robbery.  But you created a situation that was just as dangerous as anyone who did that.”

The judge meted out Rhoades’ sentence: 25 years in prison.

His crime: having sex without first disclosing he had HIV.

Officially, the charge, buried in Chapter 709 of the Iowa code, is “criminal transmission of HIV.”  But no transmission had occurred.  The man Rhoades had sex with, 22-year-old Adam Plendl, had not contracted the virus.

That’s not a surprise, because Rhoades used a condom.

And medical records show he was taking antiviral drugs that suppressed his HIV, making transmission extremely unlikely.  A national group of AIDS public health officials later submitted a brief estimating that the odds of Rhoades infecting Plendl were “likely zero or near zero.”

After his lawyers petitioned the court, Rhoades’ prison sentence was changed to five years’ probation.  But for the rest of his life — he is 39 — he will remain registered as an aggravated sex offender who cannot be alone with anyone under the age of 14, not even his nieces and nephews.

Rhoades’ is not an isolated case.  Over the last decade, there have been at least 541 cases in which people were convicted of, or pleaded guilty to, criminal charges for not disclosing that they were HIV-positive, according to a ProPublica analysis of records from 19 states.  The national tally is surely higher, because at least 35 states have laws that specifically criminalize exposing another person to HIV.  In 29 states, it is a felony.  None of the laws require transmission to occur.

Defendants in these cases were often sentenced to years — sometimes decades — in prison, even when they used a condom or took other precautions against infecting their partners.  In 60 cases for which extensive documentation could be obtained, ProPublica found just four involving complainants who actually became infected with HIV.  Even in such cases, it can be hard to prove who transmitted the virus without genetic tests matching the accused’s HIV strain to their accuser’s.

People with HIV have even done time for spitting, scratching or biting.  According to the federal Centers for Disease Control and Prevention, spitting and scratching cannot transmit HIV, and transmission through biting “is very rare and involves very specific circumstances” — namely, “severe trauma with extensive tissue damage and the presence of blood.”

Many law enforcement officials and legislators defend these laws, saying they deter people from spreading the virus and set a standard for disclosure and precautions in an ongoing epidemic.

“Shifting the burden of HIV disclosure from the infected person, who is aware of a known danger, to one who is completely unaware of their partner’s condition smacks of a ‘blame the victim’ sort of mentality,” Jerry Vander Sanden, a prosecutor in Linn County, Iowa, wrote in an email to ProPublica.  “It would be like telling a rape victim that they should have been more careful.”

Even many people with HIV support the laws.  In a recent survey of HIV-positive people in New Jersey, 90 percent said that people with the virus bore most of the responsibility to protect their partners.  More than half approved of the kind of laws that resulted in Rhoades’ sentence.

But some health and legal experts say using criminal penalties to curtail the epidemic could backfire and fuel the spread of HIV.  According to the CDC, 1.1 million Americans are currently living with HIV, but one-fifth of them don’t know it.  And studies show that about half of newly infected people got the virus from those who didn’t know they had HIV.  So relying on a partner to know, let alone disclose, their HIV status is a risky proposition.

The laws, these experts say, could exacerbate this problem:  If people can be imprisoned for knowingly exposing others to HIV, their best defense may be ignorance.  Such laws, then, provide a powerful disincentive for citizens to get tested and learn if they carry the virus.

HEALTH - Rapid HIV Test Approved

"Rapid H.I.V. Home Test Wins Federal Approval" by DONALD G. McNEIL Jr., New York Times 7/3/2012

After decades of controversy, the Food and Drug Administration approved a new H.I.V. test on Tuesday that for the first time makes it possible for Americans to learn in the privacy of their homes whether they are infected.

The availability of an H.I.V. test as easy to use as a home-pregnancy kit is yet another step in the normalization of a disease that was once seen as a mark of shame and a death sentence.

The OraQuick test, by OraSure Technologies, uses a mouth swab and gives results in 20 to 40 minutes. A previous test sold over the counter required a user to prick a finger and mail a drop of dried blood to a lab.

Dr. Anthony S. Fauci, the longtime AIDS researcher and director of the National Institute of Allergy and Infectious Diseases, called the new test a “positive step forward” and one that could help bring the 30-year-old epidemic under control.

Getting an infected person onto antiretroviral drugs lowers by as much as 96 percent the chance that he or she will transmit the virus to someone else, so testing and treatment have become crucial to prevention. About 20 percent of the 1.2 million infected Americans do not know they have the disease, the Centers for Disease Control and Prevention estimates, and about 50,000 more get infected each year.

Dr. Robert Gallo, who headed the National Institutes of Health lab that developed the first American blood test for the virus in 1984, called the F.D.A. approval “wonderful because it will get more people into care.”

The idea of a home test has long been mired in controversy. The first application for one was made in 1987, and the F.D.A. has been considering OraSure’s simple mouth-swab test since 2005.

But the history of AIDS and the human immunodeficiency virus that causes it are unique. AIDS emerged in the 1980s wrapped in a shroud of stigma. It was spread by sex, drug injections and blood transfusions. Along with hemophiliacs, heroin users and Haitians, the most vocal group of early victims was gay men, who were then in the throes of a loud and defiant liberation movement.

Because merely being tested for H.I.V. was seen as tantamount to being publicly revealed as gay or addicted to drugs, and because an H.I.V.-positive result was a death sentence, groups like the Gay Men’s Health Crisis and newspapers like The New York Native advised their members and readers to shun testing until ironclad guarantees of anonymity were put in place.

Alarmists predicted a wave of suicides if home tests were made available. At hearings, advocates for AIDS patients handed out copies of an obituary of a San Francisco man who jumped off the Golden Gate Bridge after learning he was infected. C.D.C. officials warned their F.D.A. counterparts that home testing could lead to a surge of new patients that would swamp overburdened health clinics, according to an F.D.A. document.

So, even as tests for other stigmatized diseases like syphilis were once part of getting a marriage license and home pregnancy kits became available at every corner pharmacy, H.I.V. tests lived in a special limbo, usually requiring a counseling session and the signing of a consent form, adding to the air of dread.

Even when antiretroviral drugs emerged in the mid-1990s, states were slow to rewrite laws governing testing.

Mark Harrington, the executive director of the Treatment Action Group, an AIDS advocacy organization, said in an interview that he thought such fears were “a thing of the past” now that it is clear that early treatment saves lives. “Any tool that speeds up diagnosis is really needed,” he said.

The new test has some drawbacks. While it is extremely accurate when administered by medical professionals, it is less so when used by consumers. Researchers found the home test accurate 99.98 percent of the time for people who do not have the virus. By comparison, they found it to be accurate 92 percent of the time in detecting people who do. One concern is the “window period” between the time someone gets the virus and begins to develop the antibodies to it, which the test detects. That can take up to three months.

So, while only about one person in 5,000 would get a false negative test, about one person in 12 could get a false positive.

Any positive test needs confirmation in a doctor’s office, the F.D.A. said, and people engaged in high-risk sex should test themselves regularly.

The agency does not intend for the home test to replace medical testing, but instead to provide another way for people to find out their H.I.V. status, said Dr. Karen Midthun, director of the F.D.A.’s Center for Biologics Evaluation and Research.

The home test should be available in 30,000 pharmacies, grocery stores and online retailers by October, said Douglas Michels, OraSure’s chief executive. The price has not yet been set. But he said it would be higher than the $17.50 now charged to medical professionals because the company will do more complicated packaging for the home kit, open a 24-hour question line, and advertise to high-risk groups, including gay men, blacks and Hispanics, and sexually active adults. Still, he said, it will be kept inexpensive enough to appeal to people who might want to buy several a year.

Because the F.D.A. approved the home test only for people 17 and older, retail stores may ask customers to show ID, he said. The restriction is not for medical reasons, but because only a few subjects age 14 to 16 were tested, he said, “so that was the deal we worked out with the F.D.A.”

Whether having to show identification would deter teenagers or young-looking people from buying a test is unclear. Mr. Harrington said he thought it might.

In contrast, teenage girls are not legally required to show identification to buy pregnancy tests.