Marys Medicine



www.aidsmap.comissue 159 august/ september 2006 why smoking is more likely to kill you than HIV page 4 how confidential is confidential? when can doctors disclose your HIV status to others? page 8 moving from theory to practice page 18 treating genital herpes why HIV-positive people need specific treatment guidelines page 12 what's happening in HIV vaccine research?page 3 new tipranavir side-effect warning page 16 most HIV transmitters are unaware of their status page 17

aids treatment update august/ september 2006 The long arm of law is now encroaching on the page 3 In this month's Upfront, Chris Gadd asks lives of many HIV-positive people. Criminalisation What's happening in HIV vaccine research? of HIV transmission has now led to doctors and healthcare workers being advised that they may page 4 In Smoking and HIV, we explore why it's break confidentiality if they think you are putting taken so long for studies to link smoking to lowered someone at risk of HIV infection.
life-expectancy in HIV-positive people, and ask Dr Graeme Moyle how he helps support his patients who However, the advice says that they should first tell are thinking of quitting.
you that they are planning on doing this, and that they should never go to the police to make a page 8 Ever wondered just How confidential is complaint on behalf of someone else.
confidential? NAM's resident legal expert, James Rather than be afraid of the law, though, knowing Chalmers, answers our questions about doctors and what doctors (and the police) can and can't do confidentiality based on the British HIV Association's can be empowering.
recent briefing paper, ‘HIV transmission, the law, and the work of the clinical team'.
At a recent seminar on HIV and the law, it has become clear that criminalisation has galvanised page 12 The British Association of HIV and Sexual many people into action, and on page 18 Health have produced the first ever HIV-focused Dr Matthew Weait suggests how even the most guidelines for Treating genital herpes. We examine law-abiding HIV-positive individual can become why they're necessary, and what they recommend.
an activist and positively affect change.
page 16 News in Brief reports on a warning from It's also rather ironic that, according to some the manufacturers of the anti-HIV drug, tipranavir influential US experts, HIV transmission appears to be driven mostly by people unaware of their (Aptivus) about its possible link with bleeding in HIV status. Criminalisation is hardly an incentive the brain; two new anti-HIV drug approvals in the to take an HIV test, though, is it? US, but a longer wait for the UK; a further decline in the UK's sexual health; and who is responsible for the majority of HIV transmission.
page 18 People with HIV should not be afraid of the law, argues Dr Matthew Weait, in HIV and the law. Instead, we should engage with it, and confront the issues head-on.
medical advisory panel NAM is a charity that exists to The publishers have taken all such support the fight against HIV and care as they consider reasonable in Professor Janet Darbyshire AIDS with independent, accurate, preparing this newsletter. But they aids treatment update Heather Leake Date MRPharmS up-to-date and accessible will not be held responsible for any editor Edwin J Bernard information for affected inaccuracies or mis-statements of sub-editing & proofreading Professor Brian Gazzard communities, and those working to fact contained herein. Inclusion in Professor Frances Gotch support them.
this newsletter of information on production Thomas Paterson Dr Margaret Johnson any drug or clinical trial in no design Alexander Boxill For more information, and details way represents an endorsement of printing Cambrian Printers Dr Adrian Palfreeman of our other publications and that drug or trial. This newsletter Kholoud Porter PhD services, please contact us, or visit should always be used in copyright NAM Publications our website,
conjunction with professional 2006 All rights reserved Professor Jonathan Weber medical advice.
charity number 1011220 AIDS Treatment Update For more information about ATU's was founded by Peter Scott medical review panel, please
contact details Lincoln House, 1 Brixton Road, London, SW9 6DE, UK email: [email protected] The Derek Butler Trust

aids treatment update august/ september 2006 what's happening in hiv vaccine research? Twenty five years into the AIDS However, recent studies have begun to prevent HIV infection than pandemic there is still no preventive show more promise.
vaccine against HIV infection.
Nevertheless, the development of a However, research is continuing, and antibodies (so called, because they are successful vaccine of this type could be many important lessons have been derived from a single cell) that used as well as, or in addition to, learned along the way.
neutralise HIV's ability to attach to anti-HIV drugs in order to prevent the human cells can protect against a Three expert doctors from the United dramatic loss of CD4 T-cells soon after range of HIV strains in the test tube States recently summarised the state of HIV infection, as well as reducing viral and have protected monkeys against play in HIV vaccine research in the load after infection, resulting in slower infection with viruses related to HIV.
scientific publication, Clinical Infectious disease progression and less chance of Diseases.They explain that while HIV HIV being passed on.
has thrown up many challenges to HIV vaccines cannot use traditional Promise for the future? vaccine researchers, a number of studies vaccine designs. Live ‘attenuated' Following successful safety trials, the that could lead the way to a vaccine in (weakened) HIV-based vaccines are Merck vaccine has already entered a the future are planned or underway.
too dangerous, due to the risk of HIV large, long-lasting trial to determine However, given the surprises and infection from the vaccine itself. Killed its effectiveness, while the NIH vaccine difficulties that this field has experienced HIV vaccines do not produce an is due to enter this phase next year, over the past 20 years, the doctors stop effective immune response.
marking a new phase in vaccine short of estimating when a vaccine may research. It also hoped that the recent become available.
More success has been found using £155m boost to vaccine research DNA-based vaccines to introduce Difficulties in HIV vaccine internationally from the Gates HIV's genes into the body, often using Foundation might make a difference, other harmless viruses or bacteria although the International AIDS The doctors explain that the virus has (known as 'vectors') to carry the Vaccine Initiative estimate that closer three properties that have complicated genes. HIV vaccine vectors being to £650m a year is needed to really the search for an effective vaccine.
developed at the moment include make a difference.
Firstly, after infection has taken hold variations of the adenovirus (which HIV hides its genetic material away causes the common cold). Two versions within long-lived CD4 T-cells, ready to are in development, one by Merck and start producing more HIV particles at the other by the United States any time. This means that an effective National Institute of Health (NIH).
HIV vaccine must be able to stimulate a long-lasting immune response to prevent Cellular immunity new HIV production within the body.
Recent research has also attempted to Secondly, HIV damages the very stimulate cellular immunity against immune cells (CD4 T-cells) that are HIV. This type of immunity is mediated needed for an effective vaccine; and by cell-killing CD8 T-cells or ‘cytotoxic thirdly, HIV is genetically diverse, with T-lymphocytes', which can identify and three main groups containing distinct destroy cells that are infected with subtypes, which are found in different disease-causing organisms. However, proportions across the globe.
cellular immunity is less likely to

aids treatment update august/ september 2006 Until recently, studies examining theeffects of smoking tobacco onHIV-positive individuals suggestedthat HIV-positive smokers did not dieany sooner than HIV-positivenon-smokers. Most people pointed tothe results of the gay men'sMulticenter AIDS Cohort Study, whichhad found no association betweensmoking and the risk of developingAIDS or dying1. However, since thiswas conducted in 1987, prior to theavailability of potent anti-HIVtherapy, it is likely that the negativelonger-term effects of smoking weremasked by HIV's relatively shortsurvival expectations.
In fact, even as early as 1992 evidence began to accrue that smoking increased the risk of acquiring infections that affect the lungs, such as Pneumocystis pneumonia (PCP)2. Similar conclusions regarding smoking and bacterial pneumonia3, and emphysema4, followed.
And, as the effects of potent anti-HIV therapy began to have a significant impact on life expectancy, smoking began to appear as a factor that influenced the impact of other important illnesses, such as cardiovascular disease, which was first seen in the Swiss HIV Cohort in 20015 and confirmed in several major studies since.
One of the main conclusions of a 2005 review article by respected metabolic experts Steven Grinspoon and Andrew Carr, was that "cigarette smoking is the

aids treatment update august/ september 2006 most important modifiable risk factor June, a second study, of 924 US lipid-lowering drugs and switching from among HIV-infected patients," and that women also on potent anti-HIV a protease inhibitor to a "cessation of smoking is more likely to therapy, confirmed these data. It found non-nucleoside reverse transcriptase reduce cardiovascular risk than either that HIV-positive cigarette smokers inhibitor (NNRTI) did not significantly the choice of antiretroviral therapy or had a 50% increased risk of dying reduce the risk14.
the use of any lipid-lowering therapy."6 during the study period compared with HIV-positive non-smokers, leading the More recent studies have found investigators to conclude that smoking evidence suggesting that HIV-positive negates some of the benefits of potent smokers are at an increased risk of anti-HIV therapy12.
smoking-related cancers, over and You can find your local NHS StopSmoking Service at above the risk associated with smoking The good news is that it's never too late in the HIV-negative population. Earlier to stop. Research in the general Information is also available by phone this year, investigators from John population, which calculated the risk of (0800 169 0 169 in England; 0800 Hopkins Hospital in the United States lung cancer in lifelong smokers aged 75 848 484 in Scotland; 0800 0852219 in Wales; and 0800 858 585 in found that, compared with the general at 16% (if they hadn't died of other Northern Ireland). You can also text population, the risk of lung cancer causes by then), found that this risk was GIVE UP with your full postcode to more than doubled in all HIV-positive reduced to 6% if smokers stopped at individuals, but that the risk doubled 50, 3% if smokers stopped at 40, and You local HIV support centre may again in HIV-positive smokers7. And 2% if smokers stopped at 3013.
also run a workshop specifically for another Swiss HIV Cohort study found Amongst HIV-positive people, HIV-positive people. For example, that HIV infection trebled the risk of Positive East runs stop smoking improvements in cardiovascular risk cancers of the lip, mouth, pharynx, or courses for HIV-positive people in have already been seen in a French lung compared with HIV-negative East London. For more information, study of 233 men and women, of visit, phone people, and that these cancers were whom 59% were smokers. During the 020 7791 2855, or email only seen in smokers8. HIV-positive three years of the study, only 24 of the smokers were also found have an 137 smokers stopped smoking, but this increased risk of developing cervical In addition, GMFA runs stop smoking was enough for the courses for gay men of any HIV cancer9 and kidney disease10.
investigators to detect a status in central London. The significant difference in next workshop begins on The first data to find an association their risk of future Thu 31st Aug from between smoking and reduced life expectancy in HIV-positive individuals continues each Thursday In fact, stopping were finally published last year. Here, a until 12th October. Email: smoking was the only study of 867 HIV-positive American modifiable factor that or telephone 020 7738 army veterans on potent anti-HIV 3712 for more information therapy found that smokers were twice significantly over the or visit
as likely to die during the study period three years: the use of compared with non-smokers11. This Why smoking is more likely to kill you than HIV by Edwin J Bernard

aids treatment update august/ september 2006 AIDS Treatment Update asked Dr More than ever before, then, it seems What do you say to your patients if Graeme Moyle, of London's Chelsea & that lifestyle factors - like diet, exercise you know they're smokers? Westminster Hospital, to explain the and smoking - are important for We discuss strategies around reducing impact of smoking on people living with HIV-positive people. But although cigarettes with the aim of stopping. For HIV, and how best to go about stopping.
there's a global movement to stop example, limiting the times and places people smoking, HIV-positive people, you allow yourself to smoke, and then Why has it taken so long to see an and gay men in particular, are much gradually building up control over the effect of smoking on life-expectancy in more likely to smoke than the general cigarettes. Also, using patches and gum HIV-positive people? population15. Why do you think that's to reduce cravings. I talk about putting GM: Obviously, we've known for many the savings from not smoking aside each I can only speculate, but one of the decades that smoking is bad for you day with a particular objective in mind, reasons I've heard is that ‘I'm going to and affects health in many, many ways.
like a nice holiday. To show one of the die of HIV anyway, so what does it One of the reasons we haven't seen its benefits of stopping, I calculate their matter if I smoke?' That's clearly negative effects until recently is that cardiovascular disease risk, which is something that could have been a we haven't looked for diseases that much higher if you smoke, and then show justifiable thought process fifteen years have a long lag time, like cancer or them how significantly the risk can be ago, but it's not the case today. Also, cardiovascular disease. Thanks to reduced if they stop smoking. It's all some people have said to me that potent anti-HIV therapy, it is likely that part of coming to terms with ageing with smoking helps them feel less stressed.
many people living with HIV today are HIV: I also talk about planning their Actually there's no evidence that it going to live long enough to also be pension, in contrast from the bad old reduces stress, but people do perceive prone to the chronic prevalent diseases days when it was about planning a will.
that as part of their addiction process.
that affect all ageing populations.
So we talk about planning for the future.
Certainly, withdrawing from an Since many of these diseases are In this context, stopping smoking gives a addiction may make you feel less good, smoking-related (like cancers of the better chance of reaching that future in but perpetuating the addiction doesn't mouth and lung) or increased in their a healthy condition.
make you feel any more relaxed. In prevalence by smoking (like fact, blood pressure, and a number of cardiovascular disease, chronic lung Does that mean that people who are other measures of stress, tend to disease, anal and cervical cancer), it in their 20s, or early to mid-30s don't actually increase when you're smoking makes sense to stop smoking, if you need to think about giving up smoking cigarettes, rather than reduce. So the want to live as long and as healthy a compared to people who are in their idea that people relax with a cigarette life as possible.
is actually inaccurate.
While it's very hard to measure the risk of smoking on cardiovascular disease in someone in their 20s it doesn't mean there aren't benefits to stopping sooner rather than later.
Better World Advertising ( aids treatment update august/ september 2006 However, I think the issue for younger How do you help your patients to stop Although not legal in the UK, people is that they're setting marijuana is being used by some themselves up for a chronic addictive Within our hospital, and I think this is HIV-positive people to help with pain behaviour that is going to be more broadly true of most hospital settings, symptom management and side-effects difficult to give up as the years go by.
there are stopping smoking services.
such as nausea, lack of appetite and So it's probably better to try and deal Additionally, there are many stopping insomnia. Are the risks the same as with that addiction now rather than smoking services available throughout later, and not allow it to become a the UK. The best way to access these Many people are generally taking it self-perpetuating beast that you never services is through general practitioners.
with tobacco anyway, but in reality you escape. Also, since smoking can cause Unfortunately, many HIV-positive people can't quite smoke as many joints per some problems that HIV-positive don't have GPs, or are not open about day as you might do cigarettes! Of people are already prone to, including their HIV status to their GPs. However, course, it's important to discourage the mouth sores, oral thrush, and dental there are other ways to access these use of illegal substances, but from a and gum problems, quitting at any age services (see ‘How to stop').
medical perspective, if a person has an can help improve these quite quickly.
occasional joint as part of symptom or Do any of the drug treatments that side-effect management, then the What about simply cutting down, can be used to stop smoking interact contribution to cardiovascular risk rather than stopping completely? with any anti-HIV drugs? from that sort of level of consumption One of the messages about smoking is No, neither nicotine replacement is going to be modest and probably that there are really only two choices: therapy nor bupropion (Zyban; an closer to not smoking than it would be not smoking or smoking. Smoking a antidepressant that can reduce cravings ‘milder' tar brand or smoking ten and anxiety) have any important instead of 20 a day doesn't interactions with HIV medications.
What would be your take-home substantially reduce the risk of Both of these are available on message to HIV-positive cigarette smoking-related diseases in the same prescription through your GP, but I way that stopping smoking does. Even would say that one does not necessarily You're going to live a long time with very small numbers of cigarettes per have to reveal one's HIV status to the your HIV, so you've got to now think day have a substantial cardiovascular GP in order to access them. The new about what might kill you, seeing that risk impact. Researchers from diet pill, rimonabant (Accomplia), has it's not likely to be your HIV anymore.
Denmark16 found that women who also been reported to reduce craving Smoking comes high on the list of what smoke just three cigarettes a day for cigarettes as well as for food.
might kill you in the future. So, it's double their chances of having a heart However, it doesn't have an approval sensible to stop. And the sooner you attack and of dying early; men run for this indication making it less likely stop, the better.
similar risks if they smoke six that doctors will be willing to prescribe cigarettes or a cigar each day.
it for smoking cessation.
Smoking cessation guidelines for HIV-positive patients The New York Department of Health have published the first ever smoking cessation guidelines aimed at HIV-positive individuals17. These were last updated in June 2005.
They include the following key points and recommendations: Cigarette smoking is highly prevalent among both HIV-infected patients and substance users.
Clinicians should use evidence-based interventions to promote smoking cessation in HIV-infected patients.
Clinicians should routinely assess HIV-infected patients' smoking status and readiness to quit.
Clinicians should identify and discuss barriers to quitting smoking for HIV-infected smokers who are not interested in stopping in the immediate future, but may consider it at a later time.
Clinicians should advise all smokers to quit and should offer smoking cessation assistance including pharmacotherapy to smokers who are interested in quitting.
Clinicians should follow up attempts to quit with discussions of relapse prevention. Relapses should be followed up with discussions of new strategies for the next attempt to quit.
aids treatment update august/ september 2006 When can doctors disclose your HIV status to others? by James Chalmers The British HIV Association (BHIVA) recently published their long-awaited briefing paper, ‘HIV transmission, the law, and the work of the clinical team', which came about as a response to concerns about the criminalisation of HIV transmission. The paper deals largely with issues of confidentiality and good practice, in particular the extent to which information about an HIV-positive person's status should be kept confidential, and the exceptional situations when disclosure without consent may be justified. This article presents an overview of some of the issues raised by the paper from a patient's perspective.
First of all, how concerned should The BHIVA briefing paper says that So, when can a doctor or healthcare HIV-positive people be about doctors doctors are regulated in their duty of worker choose to breach confidentiality by the General Medical Council's (GMC) guidance on Two things must be stressed: first, The GMC guidance identifies two types confidentiality1 and on serious disclosure without consent is always a of breaches of confidentiality which a communicable diseases2, like HIV. Does last resort, and secondly, it should not doctor may make "in the public this mean other healthcare workers take place without informing the interest". One of these is disclosure to patient first. Doctors are extremely prevent the patient, or a third party, reluctant to breach confidentiality (and Strictly speaking, this guidance is being exposed to a risk of death or are well aware of the possibility of addressed to doctors and not to other serious harm. Disclosure to prevent the disciplinary proceedings if they do so healthcare professionals. However, it risk of the onward transmission of HIV without very good reasons). There can be taken as an authoritative is a possible example of such a case, should never be any question of anyone reflection of sound law and ethical and the GMC's guidance on serious rushing to breach confidences, as the practice, and guidance produced for communicable diseases uses it as a BHIVA briefing paper makes clear.
non-doctors3 often refers to it for that specific example: "you may disclose reason. Other bodies have produced information to a known sexual contact guidance covering similar issues: for of a patient with HIV where you have example, the Nursing and Midwifery reason to think that the patient has not Council's Code of Professional informed that person, and cannot be Conduct4, or the Society of Sexual persuaded to do so. In such Health Advisers' Manual5. On the circumstances you should tell the particular issue of confidentiality and patient before you make the disclosure, serious communicable diseases, the and you must be prepared to justify a detail contained in the GMC's guidance decision to disclose information".6 It is makes it the logical set of standards to thought that this duty could only arise refer to in this context, and this article where the person at risk is identifiable, often refers to "doctors" for the if only because it is unlikely that there purpose of readability. The legal and would be any practical options open to a ethical framework, however, is broadly doctor to prevent onward transmission similar for all health professionals.
to unidentifiable third parties.

aids treatment update august/ september 2006 Is a doctor or healthcare worker Does a doctor ever have a duty to Are different doctors and healthcare allowed to inform the police if they breach confidentiality? workers allowed to share information think that ‘reckless' HIV transmission The answer above suggests that a doctor between each other about an has already taken place? who believes that an HIV-positive HIV-positive patient? The exception to breach confidentiality patient is putting a third party at risk of It will often be in a patient's best in the public interest does not cover contracting HIV may, exceptionally, be interests for information about their cases where serious harm has already permitted to breach their patient's right health to be shared with different occurred. Disclosures in this instance to confidentiality in order to protect that healthcare workers in order to properly would be considered to be the second third party. Such a breach of inform their treatment. The GMC's type of breach of confidentiality, and confidentiality might in fact be legally guidance on confidentiality makes two would have to be justified as truly required. If the third party is also a things clear: one, patients should be exceptional cases "where the benefits patient of the doctor concerned, then a made aware that this will happen to an individual or to society of the failure to take steps to protect that third unless they object and two, if a patient disclosure outweigh the public and the party would leave the doctor open to objects, their wishes must be respected patient's interest in keeping the civil liability - that is, liability to pay "except where this would put others at information confidential".6 A doctor damages, rather than the possibility of a risk of death or serious harm".7 The who believes that criminally reckless criminal prosecution - for failing to guidance on serious communicable transmission had taken place might prevent the onward transmission of HIV.
diseases suggests that this "may arise, consider whether this provision could A similar argument could be made where for example, when dealing with violent be used to justify reporting to the the third party was not a patient of the patients with severe mental illness or police. However, the fact that a doctor concerned but could have been disability".8 This implies that the fact criminal action may have taken place identified and warned by the doctor, that a patient is HIV-positive would does not in itself justify disclosure although it is thought that such an not of itself be enough to justify such under this heading of the GMC argument would be unlikely to succeed.
disclosure, given that universal guidance, which requires a careful precautions should be taken to balancing exercise. Doctors will bear in These points are relatively minimise transmission risks in mind that such disclosures would run hypothetical, however and so far the risk of seriously compromising no-one has been found legally liable for The BHIVA guidance reiterates the patient trust and treatment, and that a a failure to breach confidentiality.
GMC's guidance on information sharing, prosecution is unlikely to be taken Although such a failure might result in pointing out that the improper sharing forward (much less be successful) a doctor being liable to pay damages, of information could place healthcare without a willing complainant. Against such a case would be wholly workers in a catch-22 situation, this background, the BHIVA guidance exceptional. Doctors will nevertheless resulting in a situation "where (a) there takes the view that reporting a case to be conscious of the possibility of legal is a duty to disclose to a close contact the police must be the choice of the liability, and the BHIVA briefing paper and (b) this will or may make apparent patient, not the health care provider.
attempts, as far as is possible, to set out the relevant legal rules.
the earlier breach of confidentiality".
aids treatment update august/ september 2006 Are there circumstances where an Could an HIV-positive person potentially Is there a difference in the duty of HIV-positive person might not wish to sue a doctor or healthcare worker if confidentiality between a doctor at disclose information about the HIV they provide bad (or no) advice an HIV clinic based at a GUM clinic transmission risks they are taking and/or regarding HIV transmission risks? (which is governed by the 1974 NHS whether or not they have disclosed their Venereal Disease regulations) and a Throughout the English-speaking HIV status to their sexual partners? doctor at an HIV clinic based in world, there appear to be only four another department, e.g. Infectious The BHIVA guidance recommends that reported cases9 where doctors were "full, contemporaneous notes" of held liable to pay damages for having discussions with patients are kept - failed to prevent the onward The position regarding confidentiality partly because of the spectre of legal transmission of HIV. In three of the in respect of HIV and other sexually liability, but more because this is four cases, liability was found because transmitted infections (STIs) is simply good practice. It is important they had badly advised their own muddled somewhat by the National that clinicians document that they have patients - in two cases, failing to tell Health Service (Venereal Disease) properly advised patients, but patients them that they might be HIV-positive Regulations 1974. These apply to may be reluctant to disclose as the result of contaminated blood "every Strategic Health Authority, information about risky (and transfusions, and in another, negligently NHS Trust, NHS Foundation Trust and potentially criminal) behaviour if they failing to recommend an HIV test to a Primary Care Trust", and require those feel that their disclosure might be patient whose medical history and bodies to ensure that any information documented and used against them in symptoms strongly suggested that he about persons examined or treated for legal proceedings. However, it could be might be HIV-positive. In all these an STI "shall not be disclosed" except argued that provided that it is cases, the doctors concerned had badly "for the purpose of communicating documented that a person has been advised their own patients, meaning that information to a medical properly advised on issues such as that those patients had passed on HIV practitioner, or to a person employed transmission risks, to what extent is to their sexual partners. Those sexual under the direction of a medical there any clinical or practice need to partners successfully claimed damages practitioner in connection with the document disclosures that patients from the doctors.These cases highlight treatment of persons suffering from make about their behaviour? how a doctor who provides inaccurate such disease or the prevention of the advice (or no advice) on transmission spread thereof" and "for the purpose risks might face legal liability as a of such treatment or prevention".These result. The legal duty is consistent with regulations apply in England and Wales The latest edition of NAM's book, that expressly set out by GMC only, and not in other parts of the UK.
Living with HIV, includes a newly guidance: where a patient is diagnosed Although they are not limited to GUM updated chapter on HIV and the law, by with a serious communicable disease, a clinics, they apply only to information James Chalmers. Topics include doctor should set out "the nature of "obtained by officers of the Authority confidentiality; HIV transmission and the disease and its medical, social and or Trust", and so would not apply to the criminal law; immigration andasylum law; and the Disability occupational implications, as medical professionals such as GPs who Discrimination Act (DDA). You can appropriate [and] ways of protecting are not employed by such bodies.
order a copy of the book online at others from infection".10 book is also available to read aids treatment update august/ september 2006 Is any healthcare information of any In the recent case of Sarah Porter, Could semi-public information (profiles kind ever protected from use in court? police used her own personal records to on internet dating sites like Gaydar, for Confidentiality is not an absolute right.
trace former contacts in order to get a example, or a personal testimony at an If information is confidential, it should conviction. Are an HIV-positive person's HIV conference regarding past HIV not normally be disclosed without the own personal records (address book, transmission) be used as "evidence" consent of the person to whom the diary, emails) ever confidential under right of confidence belongs. A breach the law? Under what circumstances can Similarly, details of personal of confidence may have a number of the police see them? conversations or internet profiles on consequences, such as disciplinary Although medical records are subject dating sites like Gaydar would be proceedings or court action. However, to particularly stringent procedures, admissible in evidence, although in there may be cases where disclosure requiring the police to seek a court practice it might be impossibly difficult without consent is permitted or even order from a circuit judge to examine to prove that an internet profile required by law.
them, a person's own personal contained particular information at a information (such as diaries, letters or specified date in the past when an Confidential information is different emails) will normally be subject only to offence was alleged to have taken place.
from ‘privileged' information, which the general rules governing search applies to communications between an warrants. These require only reasonable What about unlinked anonymous individual and his or her lawyer, which grounds for believing that the premises testing and confidentiality? the lawyer cannot be forced to disclose to be searched will contain material Since 1990, HIV prevalence in the UK without the client's consent.
which is "relevant evidence" of has been estimated by use of unlinked Consequently, confidential information "substantial value" to the investigation anonymous surveillance programmes.
can be used by the criminal justice of an indictable offence.11 That is These involve using residual blood left system (or, indeed, the civil courts), and demonstrated vividly by Sarah Porter's over from samples taken for other one should assume, therefore, that any case, where it appears from newspaper purposes (such as syphilis testing).
information held by health reports that the initial complaint to the Although individuals can request that professionals, or indeed by HIV-positive police was made by a former partner of their blood is not used in such persons themselves, is potentially Porter's who had not himself programmes, no explicit consent is available to the police in conducting a contracted HIV from her, and the sought for this testing. This is because criminal investigation, and to a criminal police searched her flat for documents the sample is irreversibly unlinked from court thereafter. Proper procedures - which led them to a former sexual its source before the test takes place, and such as the obtaining of search partner who had become HIV-positive so the result and any further residual warrants or court orders - must always after their two-year relationship.
blood cannot be linked back to the be followed, however.
individual concerned. This means that no information about an individual's HIVstatus can be obtained from these test results, which are only used to estimate James Chalmers is a senior lecturer in law at the University of Aberdeen. He was one HIV prevalence in wider populations.
of the authors of the BHIVA briefing paper, but writes here in a personal capacity. Thisarticle was written during the consultation period for the draft guidance, which closed Because of this, although results of tests on July 21st. Consequently some of the recommendations may change in the final like this have no special legal protection version. ATU will keep you updated on any changes.
from being used as evidence in court, they would in practice be of no evidential value whatsoever.
aids treatment update august/ september 2006 treating genital herpes The first ever comprehensive set of guidelines for the management of sexually transmitted infections (STIs) in HIV-positive individuals were recently published by the people need specific British Association for Sexual Health and HIV (BASHH)1. treatment guidelines Although many STIs in HIV-positive people can be managed in exactly the same way as those without HIV infection, BASHH singled out genital herpes (caused by one of two herpes simplex viruses, or HSV), as well as genital warts (see ATU 151, November 2005) and syphilis (see ATU 157, by Edwin J Bernard and Adam Legge June 2006) for special attention. This is because the natural history of untreated genital herpes in HIV-positive individuals is significantly different from HIV-negative individuals in two ways: Herpes viruses activate HIV, making it easier for HIV to infect certain cells, which may lead to faster HIV disease Genital herpes infection increases the risk of sexual HIV transmission.
aids treatment update august/ september 2006 Does HSV affect me? blood and genitals, and making onward Due to the fact that HIV is often HIV transmission more likely7,8.
sexually transmitted, and genital In addition, the course of genital herpes is always sexually transmitted, herpes in HIV-positive people with very Herpes simplex virus (HSV) is HSV infection is a concern for many a member of the herpes virus low CD4 counts (usually below 100 people living with HIV. Latest figures family, which also includes cells/mm3) can be quite severe: ulcers from the United Kingdom's Health varicella zoster virus (VZV, may persist much longer, be more Protection Agency2 show that the which causes chickenpox and extensive, and more painful.
number of new cases of genital herpes shingles) and cytomegalovirus Unfortunately, having a low CD4 count rose four per cent last year, although (CMV, which can lead to eye, new diagnoses have remained under also reduces the chances that gut, lung, nerve and brain 20,000 a year since they dramatically anti-HSV drug therapy will work well.
problems). Once infected, HSV increased at the beginning of this However, people with higher CD4 stays in skin and nerve cells century. There are few UK data on how counts - whether or not they are on many people are currently living with anti-HIV therapy - experience HSV genital herpes infection, but United There are two main types of infection similar to HIV-negative States data suggest that about one in HSV. HSV-1 is the usual cause individuals: the outbreaks tend to be every four women and about one in of cold sores in and around the localised, and usually clear up within a every five men have an HSV infection.
mouth, also known as oral week or two.
However, it is thought that up to four herpes. HSV-2 is the usual in every five HIV-positive individuals "Most of the evidence on how HSV cause of genital herpes, which are also infected with genital herpes3.
interacts with HIV come from the era affects the genital area, Unfortunately, many people with before effective anti-HIV therapy," including the rectum/anus.
genital herpes are unaware of their explains Dr Rak Nandwani, a consultant However, HSV-1 can also infect infection. Data from the US suggest physician at the Sandyford Initiative in the genital area, and HSV-2 that fewer than one-in-ten people with Glasgow and lead author of the can also infect the mouth area.
genital herpes know they have it.4 BASHH guidelines. "In fact, genital The BASHH guidelines focus herpes was considered so severe in those on HSV-2, but they are relevant How HIV and HSV interact days that genital herpes lesions lasting for anyone who has an herpes There is increasing evidence that the for longer than a four weeks was made infection of any type that twin epidemics of sexually transmitted an AIDS-defining condition.
affects the genital area.
HIV infection and HSV infection are linked, primarily because HSV can "However," he continues, "now it Although both types of HSV increase HIV viral loads, and also would be fair to say that if your CD4 can remain symptom-free for because the ulcers caused by genital counts are good then HSV is likely to long periods of time, the virus herpes make it easier for HIV to be be no more a problem for you than for can still be shed - and, transmitted during sex.
someone who isn't HIV infected." therefore, passed on - in genital fluids, even when there are no A 2001 study from Uganda, which Treating the first episode symptoms. Symptoms appear examined the factors influencing the For people with good immune function, when HSV becomes activated - transmission of HIV between the first episode of genital herpes may when the immune system is monogamous partners of different HIV be symptom-free. However, if symptoms weakened; in situations of status, found that the two most do occur they can be pronounced and stress; during a cold; or on important factors for HIV usually occur within two weeks of being exposure to strong ultraviolet transmission were HIV viral load in infected with HSV. They typically light - and this can result in the HIV-positive partner and the appear as one or more blisters on or very painful skin eruptions.
presence of genital ulceration, most around the genitals or rectum. These commonly caused by HSV5.
blisters then break, leaving tender ulcers Nevertheless, unless the virus that can take two to four weeks to heal; infects the brain and causes The following year, an analysis of all inflammation, HSV infection is the existing data concluded that people a second-crop of sores may then appear.
rarely life-threatening. This infected with genital herpes were more The first episode might also include seldom happens in people with than twice as likely to become infected flu-like symptoms, including fever and HIV, possibly because the with HIV than people who didn't have swollen glands.
immune system's ability to HSV infection6.
The BASHH guidelines recommend mount an inflammatory Other studies have suggested that HSV that the first episode of genital herpes response is impaired.
can activate HIV replication, in HIV-positive people should be increasing the amount of HIV in the treated with aciclovir (Zovirax).
aids treatment update august/ september 2006 Although this is available In severe first-time cases, the guidelines of symptomatic genital herpes to over-the-counter as a cream for recommend starting intravenous therapy reduce the duration and severity of the treating cold sores, it is used here in with aciclovir at 5-10mg per kilogram episode is less costly, it is also likely tablet form (400mg five times a day of body weight every eight hours. If new to be less effective than daily for seven to ten days). This is higher lesions are still forming after three to suppressive therapy in preventing than the standard recommended dose five days of therapy, the guidelines HSV-2 (and, potentially, HIV-1) for HIV-negative individuals.
recommend that a repeat viral culture transmission and in improving should be taken to test that the HSV is survival, because most HSV-2 "We've recommended that all people not resistant to medication (see reactivation is subclinical. Given the with HIV get higher doses of aciclovir ‘Drug-resistant genital herpes').
high seroprevalence of HSV-2 among for the first episode," notes Dr HIV-infected persons, long-term Nandwani, who says that the Episodic or suppressive treatment of HSV-2 infection could recommendations are based upon also have substantial public health expert opinion and adds that although Reactivations of HSV tend to be more this intensified treatment "is not frequent and can be more severe in currently practised by many doctors," people with HIV - especially in those Treating recurrences he hopes the guidelines will change that.
with CD4 counts of less than 50 If you choose to take episodic cells/mm3, according to Dr Barton.
treatment, the guidelines state that Aciclovir has been used to treat genital "Optimising the control of HIV is of aciclovir, famciclovir and valaciclovir herpes for almost 20 years, and is the utmost importance when managing can all be used.
considered to be safe and effective, recurrent genital herpes and once with a very low incidence of that's been done you can start to look They recommend one of the following side-effects when taken orally.
at whether you're going to use However, the drug needs to be taken anti-herpes drugs for episodic or frequently due to its poor aciclovir 400mg three times daily suppressive therapy," he says.
bioavailability: only about a fifth of the for five to ten days total amount of the drug taken by Episodic treatment involves waiting to aciclovir 200mg five times daily for mouth makes it into the bloodstream.
take anti-herpes medication as soon as Adhering to aciclovir five times a day symptoms occur, whereas suppressive may not be possible for some people, therapy may be more effective for famciclovir 500mg twice daily for and so the guidelines recommend as people who have more frequent alternatives either valaciclovir attacks, although this involves taking valaciclovir 1g twice daily for five (Valtrex) 1 gram twice daily for ten to ten days.
days or famciclovir (Famvir) "The decision between taking episodic 250-750mg three times a day for ten or suppressive therapy is very much Starting anti-HSV therapy as soon as days. Although studies have found dependent on a discussion between a recurrence is suspected is crucial to these drugs are equivalent in doctor and patient," stresses Dr the success of therapy. Some people effectiveness to aciclovir9,10, and none Barton. "If you're getting recurrences with recurrent genital herpes get a have significant interactions with once a month, or you're finding the tingling sensation where a lesion is anti-HIV drugs, they cost more which episodes very distressing, then you going to form, whereas others might may mean you wouldn't automatically might well want to consider taking not know a recurrence is on the way be prescribed these alternatives unless suppressive therapy." until they see the characteristic blister you specifically asked for them.
start to form.
This choice contrasts with current "Most people in the UK will be recommendations from the United "You can bet that whenever you get a prescribed aciclovir," explains BASHH States, which suggest all HIV-positive recurrence that it's going to be at the President, Dr Simon Barton of people, even those on potent anti-HIV most awkward time," Dr Nandwani London's Chelsea & Westminster therapy, receive suppressive therapy.
remarks wryly, "usually when you're Hospital, "because that drug is now "We recommend that HIV-infected about to go on holiday or at the start available in generic form and is, patients with HSV-2 coinfection of the weekend when it's impossible to therefore, cheaper." He adds that, receive counselling about genital get a clinic appointment. That is why it "although the other antivirals might be herpes and be offered suppressive is important to make sure you have a easier to take [due to less pill burden], aciclovir therapy," write Lara Strick stash of aciclovir at home so you can there's no evidence that they're any and colleagues from the University of start taking it whenever you feel a better at managing a recurrence." Seattle. "Although episodic treatment recurrence coming on." aids treatment update august/ september 2006 The new guidelines do not make Drug-resistant genital herpes But the preferred treatment for specific recommendations for Occasionally herpes viruses become drug-resistant herpes is intravenous suppressive therapy, but BASHH have resistant to anti-HSV drugs. This may cidofovir or foscarnet. Both of these previously published recommendations be more likely if someone has been on medications are more regularly used to in 2001 for the general population suppressive aciclovir therapy for a long treat CMV infection and have with genital herpes: time. Although resistance is rare in substantial side-effects, notably kidney people with high CD4 counts, toxicity. Consequently, these should not aciclovir 400mg twice daily or "aciclovir-resistant strains have been normally be given to anyone with 200mg four times daily found in between five to seven percent pre-existing kidney problems, or those or famciclovir 250mg twice daily of isolates from genital herpes lesions in taking drugs that might also cause HIV-infected patients," notes kidney problems.
or valaciclovir 500mg daily Dr Nandwani, "but these have tended to be in people with lower CD4 counts." The future of herpes therapy Dr Barton recommends that his Simon Barton believes that any new patients try aciclovir 400mg twice Consequently, the guidelines recommend drug will have to go some way to better daily or, "for those with very low CD4 that if lesions are persistent, or recur in currently available options. "Aciclovir is counts, 400mg three times daily or someone receiving anti-HSV therapy, cheap and very effective if used early valaciclovir 500mg twice daily." then herpes resistance should be enough in herpes infections," he says, suspected and a viral sample taken for The guidelines make it clear, however, "and it is also very safe. We use it at that suppressive anti-herpes therapy in very high doses even in children without HIV-positive individuals may be less substantial problems." Partially resistant HSV strains can effective than in HIV-negative people.
sometimes be treated with high-dose Currently, two helicase-primase They also recommend that if you intravenous aciclovir but fully inhibitors are being studied by Bayer decide to try suppressive therapy, it aciclovir-resistant strains are also and Boehringer Ingelheim. These stop makes sense - especially for people resistant to valaciclovir and another HSV replication by blocking the with ‘undetectable' HIV viral loads and anti-herpes drug, ganciclovir activity of two enzymes - helicase and higher CD4 counts - to interrupt (Cymevene), and are also likely to be primase - which work together to anti-herpes treatment every so often in resistant to famciclovir.
make new DNA copies of the virus.
order to check whether the recurrences are as troublesome as before.
However, the guidelines make it clear A topical cream is also in that there are still options for people development. "There were some very with resistant HSV. Both topical intriguing results from a study of a foscarnet (Foscavir, 1%) version of the genital warts treatment cream and cidofovir imiquimod, called resimiquimod," (Vistide, 1%) gel have notes Dr Barton, "which, when applied been shown to produce topically, lengthened the time between significant benefits herpes recurrences. However, that in healing lesions, study was done a few years ago and reducing pain and we're still waiting for further "Of course the Holy Grail is a herpes treatment vaccine," adds Dr Nandwani, "but results so far have been disappointing." And although GlaxoSmithKline are currently developing a vaccine to prevent HSV infection, it only appears to protect women, and like the recently US-approved HPV vaccine Gardasil, (trifluridine, TFT) needs to given before sexual maturity either on its own or in to be most effective. Currently, a major trial in young women, called HERPEVAC, is underway, and results are due in 2008.
aids treatment update august/ september 2006 Tipranavir may rarely Most peoplewho transmit be associated with bleeding in the brain Boehringer Ingelheim, the manufacturers of the protease inhibitor (PI), tipranavir (Aptivus) have issued a warning about a newly-discovered, potentially fatal side-effect after 13 of the 6,840 people who took ritonavir-boosted tipranavir in clinical trials developed bleeding within HIV-positive individuals who are the skull, known medically as intracranial haemorrhage. Sadly, eight of these people died.
unaware of their infection may More than half of the people who developed this rare problem - which affected one person account for between 54% and out of every 500 - had pre-existing risk-factors, however. These included problems with blood 70% of all new sexually clotting, lesions on the brain, head injury, recent brain surgery, and high blood pressure.
transmitted HIV infections in the Alcohol abuse and other medicines known to increase the risk of bleeding were also a factor.
United States, according to a Tipranavir is only approved for treatment-experienced people with limited treatment options.
calculation from the US Centers At the time of licensing, in 2005, liver-related side-effects were noted to be of concern, and it for Disease Control and Prevention is recommended that people taking the drug have their liver function regularly monitored.
Since the bleeding developed an average of 525 days after people started tipranavir/ritonavir, However, the CDC calculation does it has taken this long after the drug was approved for this problem to appear.
not take into account data published The warning is particular pertinent to HIV-positive people with haemophilia, since they are last year which suggest that in the already at risk of 'a bleed in the brain' regardless of HIV status. Some test-tube studies and five months immediately following animal experiments have found some reductions in the ability of blood clots to form in the seroconversion, HIV transmission presence of tipranavir, and Boehringer Ingelheim is now carrying out more investigations into risk is approximately ten times the link between tipranavir and bleeding. However, there have been case reports of this greater than during chronic problem occurring with other PIs, and a 2001 study from the US Centers for Disease Control found that the risk of bleeding within the skull was increased in HIV-positive In addition, the CDC's data are haemophiliacs taking PIs.
based on one-in-four individuals Two weeks prior to this warning being issued, Boehringer Ingelheim also announced that they being unaware of their HIV had halted a study of tipranavir in people who had never previously taken anti-HIV drugs, infection. In the United Kingdom, it just over a year into a three-year study. This is because, compared to those receiving is estimated that one-in-three HIV lopinavir/ritonavir (Kaletra), significantly fewer people taking ritonavir-boosted tipranavir infections remain undiagnosed, had a viral load below 50 copies/ml.
which suggests that the proportion of new HIV infections from This study used a lower dose (100mg twice daily) of ritonavir to boost tipranavir than undiagnosed HIV-positive approved for treatment-experienced patients (200mg twice daily). This is because a previous individuals in the UK may be even study of tipranavir in treatment-naive individuals using the higher ritonavir dose had been higher here than in the US.
stopped due to a high rate of asymptomatic liver enzyme elevations.
Understanding who is more likely to It is now extremely unlikely that tipranavir will ever be approved for people who have never transmit HIV may be helpful in the taken anti-HIV drugs before, but the drug company points out that these results do not debate around the criminalisation of change its suitability for people with few treatment options, for whom the PI is licensed.
HIV transmission, which tends to Anyone taking tipranavir who has any concerns about this drug should first talk to their penalise people already aware of doctor before stopping or changing any of their anti-HIV drugs.
their HIV status.
aids treatment update august/ september 2006 A new drug and a new combination receive US approval The United States Food and Drug Administration (FDA) have approved a new protease inhibitor (PI), darunavir (TMC114, Prezista), forHIV-positive individuals whose infection is not responding to treatment with other anti-HIV drugs.The FDA has also approved a triple drug anti-HIV combination in one pill, marketed as Atripla, which contains efavirenz (Sustiva) and Truvada (tenofovir and FTC).
The US approval of darunavir was granted after the drug's manufacturer, Tibotec, presented data from two randomised studies known as POWER 1 and POWER 2, which examined the risks and benefits of the drug in people with substantial treatment experience.
Together, these studies found that those taking ritonavir-boosted darunavir had significantly larger reductions in their viral loads and higher CD4 count increases than those taking other ritonavir-boosted PIs. Both groups of patients took their PIs with other anti-HIV drugs, including nucleoside reverse transcriptase inhibitors (NRTIs), chosen on the basis of genetic testing. In addition, almost half of the patients were taking the fusion inhibitor T-20 (enfuvirtide, Fuzeon). The main side-effects seen in the studies were diarrhoea,nausea and headache. Around 7% of the patients also had skin rashes which were serious in a few cases.
The US approval of Atripla is significant because it marks the first collaboration between drug companies to create a fixed-dose anti-HIV drug combination. The drug contains 600mg of Bristol-Myers Squibb's efavirenz and Gilead's Truvada, which contains 300mg oftenofovir and 200mg of emtricitabine (FTC). Atripla is a single tablet taken once a day, with or without food, and contains one of themost frequently prescribed regimens worldwide for the treatment of people with HIV who have not previously taken any anti-HIV drugs.
The triple combination pill is not likely to be approved in Europe until 2007; however European approval of darunavir is expected later this year.
NAM nutrition booklet - correction ddI doses and their food restrictions Further decline for UK's sexual health ddI doses and their food restrictions There is an error in the current edition of the 2005 data from the UK's Health Protection Agency (HPA) saw a 3% increase in NAM Nutrition booklet, distributed with the last the number of sexually transmitted infections (STIs) diagnosed in genitourinary edition of ATU, concerning the two types of ddI medicine (GUM) clinics in the UK.
(didanosine, Videx) and their food restrictions.
Chlamydia remains the most commonly diagnosed STI in the UK, possibly as a The entries for ddI on page 14 of the booklet result of the scaling-up of the National Chlamydia Screening Programme. In 2005, 109,832 new cases were diagnosed - a 5% increase on the previous year.
ddI (didanosine, Videx) 100/200mg tablets:Essential to take on an empty stomach, at least 30 Genital warts were the second most commonly diagnosed STI in 2005, with an increase minutes before or two hours after eating.Take at of 1% from the previous year to 81,203 cases. Genital warts are caused by human least one hour apart from indinavir (Crixivan).
papilloma virus (HPV), which is also associated with cervical and anal cancers.
The liquid requirement for ddI 100/200mg tablets: New diagnoses of syphilis continued to significantly increase in 2005, up by 23% Must be taken with cold non-carbonated water orclear apple juice (which improves the taste).
in 2004 to 2,807. Sixty percent of syphilis cases were seen in gay and bisexual men, many of whom were also HIV-positive.
EC ddI (didanosine, Videx EC) capsules:Essential to take on an empty stomach, at least New diagnoses of genital herpes increased by 4% (from 19,074 in 2004 to two hours before or two hours after eating.
19,771 in 2005), although they have remained under 20,000 since they During this period you can drink cold water only.
dramatically increased at the turn of the century.
Apologies for any confusion. The booklet is being Finally, some good news: the number of new cases of gonorrhoea fell by 13%, corrected and if you would like an amended copyplease email [email protected], or call from 22,350 in 2004 to 19,495 in 2005, with fewer cases reported across all 020 7840 0050.
English regions.
aids treatment update august / september 2006 In June, the final of three seminars entitled, HIV/AIDS and Law: Theory,Practice and Policy, took place at Keele University. The seminars wereorganised by Dr Matthew Weait, lecturer in law at Keele University, incollaboration with the African HIV Policy Network (AHPN), BirkbeckCollege and George House Trust (GHT), and was funded by the Economicand Social Research Council.
The seminars brought together academics, legal and medical practitioners, people living with HIV, as well as representatives of the major HIV charities, in order to explore the ways in which the law is having an impact on people living with HIV. This includes recent calls for mandatory HIV-testing of immigrants; lack of access to treatment, dispersal and deportation of many so-called asylum seekers; and HIV and sex education in schools.
Although the series examined all these issues, the criminalisation of HIV transmission was the galvanising force behind the seminars.
communication for all of these issues Does it mean not telling the truth It's been a long time since the major and bring together best practice," about a sexual history to an HIV or HIV charities all came together to explains Dr Weait, "where trusted GU clinician, which is critical to work towards a common goal.
knowledge and legal expertise could be contact tracing? Will it make people Representatives of AHPN, GHT, HIV shared between everyone working in think twice about voluntary HIV Scotland, the National AIDS Trust the HIV sector. Funding it might be testing, or being honest about the (NAT), Positively Women, Terrence difficult, though, because some people results of that test? If that's the case Higgins Trust (THT), the UK Coalition might see it as funding the defence of then we've lost a significant battle in of People Living with HIV and AIDS ‘wicked people'." the war against HIV." (UKC), and NAM - all agreed that Arrest me/defend me there had been a lack of "joined-up The June seminar took place the weekend thinking" in their response to after Sarah Porter was imprisoned for criminalisation, and other The criminalisation of HIV ‘reckless' HIV transmission. Her case pressing legal issues, and that this transmission does evoke some difficult appeared to break worryingly new needed to be rectified.
ethical and moral issues. "I think it's ground. Brixton police had launched a really important to recognise the "We needed to come together to manpower-intensive inquiry to actively long-term impact of these identify ways in which links can be find her past sexual partners, when the prosecutions, whatever one's ethical or established to ensure that the kind of only activity reported to them was moral stance," argues Dr Weait.
lack of communication that's unprotected sex by an HIV-positive "Criminal trials, whatever their other happened in the past doesn't happen person, which is not in itself a crime.
effects, affirm in the public and again," says Dr Weait, who has been Since then, two different police forces in popular imagination that HIV-positive actively involved in providing legal the Midlands have gone one step further people can only be understood as research support to the HIV voluntary and used the local press to ‘fish' for the vectors of onwards transmission." sector for the last decade. "The sexual partners of people they are university provided a neutral space He points to criminalisations' other currently investigating for ‘reckless' where people could speak freely possible harms. "Does it mean that without being constrained by other people are so afraid of disclosing their It's hardly surprising that there was a people's budgets or agendas." status to sexual partners, because of renewed call for individual activism at One of the most tangible outcomes was the kind of coverage that people with the seminar.
strong support for the development of HIV get in the press as a result of the a UK HIV/AIDS Legal Network. "This prosecutions, that they're not going to One suggestion was to stand outside the would operate as a central point of disclose despite the consequences? courtroom wherever a criminalisation aids treatment update august / september 2006 references to all articles upfront [page three]1. Duerr A et al. Clin Infect Dis 43: 500-511, 2006.
smoking & hiv [page four]1. Galai N et al. J Acquir Immune Defic Syndr Hum Retrovirol 14: 451-458, 1997.
2. Buskin SE et al. 8th Intl AIDS Conf, Amsterdam, abs WeC1030, 1992.
3. Burns DN et al. J Acquir Immune Defic Syndr Hum Retrovirol 13: 374-383, 1996; Conley LJ et al.
AIDS 10: 1121-1126, 1996.
4. Diaz P et al. Ann Intern Med 132: 369-372, 2000.
5. Depairon M et al. AIDS 15: 239-334, 2001.
6. Grinspoon S et al. NEJM. 6;352(1): 48-62, 2005.
7. Engels EA. J Clin Oncol. 20;24(9):1383-1388, 8. Clifford GM et al. J Natl Cancer Instl 16;97(6): 425-432, 2005.
9. Minkoff H et al. JID, 189: 1821-1828, 2004.
10. Miguez-Burbano MJ et al. 15th Intl AIDS Conf, Bangkok, abstract MoPeB3274, 2004.
11. Crothers K et al. J Gen Intern Med 20 (12), 1142- 12. Feldman JG et al. Am J Public Health 96(6):1060- 13. Peto R et al. BMJ 321(7257): 323-329, 2000.
14. Thiebaut R et al. AIDS: 19(7): 729 - 731, 2005.
Moving from theory to practice 15. Smith C et al., Glasgow, abs P162, 200216. Prescott E. J Epidemiol Community Health 56: 702- by Edwin J Bernard how confidential is confidential [page eight]1. GMC. Confidentiality: Protecting and Providing Information (April 2004) www.gmc- trial is being held, holding a two-sided police from expressing their opinion placard that reads: ‘Arrest me' and about criminalisation cases, which 2. GMC. Serious Communicable Diseases: Guidance to ‘Defend me', to make the point that seems to me to be unethical, by Doctors (October 1997) www.gmc- most HIV-positive people have been complaining to the Independent Police es.asp. Hereafter, Serious Communicable Diseases.
‘victims', and are potentially 3. See, for example, Royal College of Nursing, Confidentiality: RCN Guidance for Occupational ‘perpetrators', of onward transmission.
Health Nurses, 2005.
"It could be trying to change the way "One of the things that has prevented 4. Nursing and Midwifery Council, The NMC Code of the media covers only the negative Professional Conduct: Standards for Conduct, that kind of activism from happening aspects of HIV-positive life, by raising Performance and Ethics, 2004. Available via with HIV since the advent of potent the issue in opinion-making 5. Society of Sexual Health Advisers, The Manual for anti-HIV therapy in developed Sexual Health Advisers, 2004.
newspapers. And, perhaps, if you are countries is that HIV isn't seen as a 6. Serious Communicable Diseases, para 22.
crisis anymore," comments Dr Weait.
confident in your diagnosis, and feel 7. Confidentiality, para 10.
8. Serious Communicable Diseases, para 19.
"With the exception of these able to disclose your status, you could, 9. Chalmers J. Intl J STD AIDS 15: 782-788, 2004.
criminalisation cases, HIV is off the for example, talk about the importance 10. Serious Communicable Diseases, para 18.
11. Police and Criminal Evidence Act 1984, section 8.
national public agenda." of sex education in schools, or of condom provision in prisons.
treating genital herpes [page twelve] Although placard waving might not 1. Nandwani R et al. www.bashh.org2. suit everyone, Dr Weait has other "My hope is that HIV-positive people suggestions as to how we can will realise that the law isn't empower ourselves when it comes to necessarily something to be afraid of; 4. Hook E. Ann Intern Med 143(10): 751-752, 2005.
5. Gray RH et al. Lancet 357: 1149-1153, 2001.
HIV and the law.
that the law isn't a language that only 6. Wald A et al. JID 185: 42-52, 2002.
7. Gray RH et al. JID 189:1209-1215, 2004.
"What is most important is that you other people can speak; and that it is 8. Schacker T et al. JID 186: 1718-1725, 2004.
9. Romanowski B et al. AIDS 14(9): 1211-1217, pursue the form of political possible to engage with the law engagement that suits you," he says.
directly and in an informed way to 10. Conant MA et al. Int J STD AIDS 13(1): 12-21, "That could be trying to stop the achieve real change." 11. Strick LB et al. Clin Infect Dis 43(3): 347-356, 12. Posavad et al. JID 190: 693-696, 2004.
further information news in brief [page twelve] Tipranavir may rarely be associated with bleeding in the Presentations from the seminar series are available for download at the UK Law and HIV/AIDS Project: 1. Nuss R. Am J Hematology. 68 (1), 37-42, 2001.
Most people who transmit HIV unaware they areHIV-positive1. Marks G et al. AIDS 20(10); 1447-1450, 2006.
The Independent Police Complaints Commission website is at: thanks to our funders NAM's treatments information for people living with HIV is provided free thanks to the generosity of: Abbott Laboratories International & UK; Access 4; Ajahma Charitable Trust; Alan & Nesta Ferguson Charitable Settlement; Avexa; Birmingham PCT; The Body Shop Foundation; Boehringer Ingelheim International & UK; Bolton PCT; Bristol-Myers Squibb UK HIV & Hepatitis; British HIV Association (BHIVA); Cleopatra Trust; Corkery Group; Crusaid; Derek Butler Trust; Diana, Princess of Wales Memorial Fund; Government of the United Kingdom, Department of Health; East Sussex, Brighton & Hove area PCTs; The Elton John AIDS Foundation; Gilead International & UK; GlaxoSmithKline UK; Healthsure Charitable Trust; Hugh Fraser Foundation; International HIV/ AIDS Alliance; Janssen-Cilag; Lloyds TSB Foundation for England and Wales; Lloyds TSB Foundation for Northern Ireland; London HIV & GUM Commissioning Consortium; MAC AIDS Fund; Merck Sharp & Dohme UK & International; Newcastle PCT; Norfolk PCT; Manchester city area PCTs; Miss Agnes H Hunter's Trust; Merton Social Services; Peter Moores A clearly written and comprehensive Foundation; Pfizer UK & International; Positive Action (GSK); Roche Products UK Hep C; Roche Products guide to the medical side of HIV and International & UK; The Russell Trust; Salford PCT; Shire Pharmaceuticals; South East Essex PCTs; South West AIDS, from diagnosis to treatment.
Essex PCTs; St. Stephen's AIDS Trust; Stockport Social Services; Thomas Sivewright Catto Charitable Settlement; Tibotec; Virco; West Sussex PCTs; Worcestershire PCT The immune system and HIV.
NAM would also like to acknowledge the generous support of individual donors, and in particular Gavin Hay A to Z of symptoms and illnesses.
Starting, changing and interrupting treatment.
Body fat and metabolic changes.
Where to find out more about HIV Find out more about HIV treatment:NAM's factsheets, booklets, directories andwebsite, keep you up to date about keytopics, and are designed to help you makeyour healthcare and HIV treatmentdecisions. Contact NAM to find out more and order your copies.
Information events in London simply call 020 7840 0050 On the last Monday of every month, an expert to order your copy speaker discusses an HIV treatment relatedtopic. Entry is free. The next topic is For professionals/ organisations ‘Feedback from the International AIDS prices, please contact NAM Conference, Toronto', and will be held on 21stAugust 2006. For more details, go
www.aidsmap.comVisit our website for the latest news aboutHIV & AIDS and a fully searchable It's the single best source of clear, treatments database and a complete list of comprehensive and up-to-date HIV treatment centres in the UK.
information about every aspect of THT Direct Phoneline Offers information and advice to anyoneinfected, affected or concerned about issues Every patient should have a copy.
relating to HIV and sexual health.
BMA Medical Book Competition, 2005 0845 1221 200Mon-Fri, 10am-10pm Sat-Sun, 12pm-6pm i-Base Treatment PhonelineA HIV Treatment phoneline; where you candiscuss your issues with a treatment expert.
NAM, Lincoln House, 1 Brixton Road, London, SW9 6DE, UK tel +44 (0)20 7840 0050 fax +44 (0)20 7735 5351 email [email protected] web Mon-Wed, 12pm-4pm


Polymeric Micelles – The Future of Oral Drug Delivery Department of Chemical and Biomolecular Engineering University of Notre Dame, Notre Dame, IN 46556 Abstract This work examines current advancements in polymeric micelles as a method for oral delivery of poorly water-soluble drugs. The oral route presents several barriers to drug delivery that the chosen vesicle must overcome. Polymeric micelles have several physical properties, including molecular weight and copolymer block composition, which can be tailored to alter the vesicle structure and overcome these barriers. Examination of current research demonstrates the ability of polymeric micelles to respond to external stimuli, such as pH, allowing for controlled release of encapsulated drugs in the gastrointestinal tract. Lastly, with patients preferring the oral drug delivery route to the intravenous delivery route, it was shown that polymeric micelles can achieve the same desired pharmacological dose via either delivery method. These factors make polymeric micelles appear to be a viable option for future oral drug delivery applications. 1. Introduction 1.1 Clinical Relevance

En abordant le sujet SE SOIGNER – LES PREMIERS SECOURS, nous entrons dans unepartie non négligeable de la survie. Accès rapide - - - - - HYGIÈNE ET SOIN – HYGIÈNE La base de l'hygiène c'est l'eau. Il est très risqué de boire de l'eau du robinet, elle peut êtreimpure à la consommation voire pire. Il existe une solution pour prévenir pas mal derisques, les pastilles Micropure Forte.