Remember the CMAAO - UU Campaign

• Having an undetectable viral load when on HIV treatment (ART) also stops HIV transmission
• For > 20 years it is known that ART reduces HIV transmission but now it is clear that the risk is not just reduced but stopped completely.
• ART protects your partners.
• You don’t need to use condoms if you were only using them to stop HIV provided you take ART every day and have undetectable viral load for at least three months and continue to take meds without missing doses.
• The evidence for U=U comes from studies with both gay and straight couples, and for all types of sex. 
• There should be no doubt that a person with sustained, undetectable levels of HIV in their blood cannot transmit HIV to their sexual partners.

HIV Single Tablet (2 for prevention and 3 for treatment)

1.              Abacavir-lamivudine-dolutegravir

2.              Elvitegravir-cobicistat-emtricitabine-tenofovir disoproxil fumarate,

3.              Elvitegravir-cobicistat-emtricitabine-tenofovir alafenamide

4.              Bictegravir-emtricitabine-tenofovir alafenamide

5.              Nucleoside combination (tenofovir disoproxil fumarate-emtricitabine, tenofovir alafenamide-emtricitabine, or abacavir-lamivudine) be used with EITHER a boosted protease inhibitor (ritonavir-boosted lopinavir, ritonavir-boosted darunavir) OR an integrase strand transfer inhibitor (raltegravir, elvitegravir/cobicistat, dolutegravir, or bictegravir)

6.              Cipla: Stavudine + Lamivudine + Nevirapine

7.              Cipla: TLD (tenofovir (TDF), lamivudine (3TC) and dolutegravir (DTG).

Pre exposure prophylaxis:

Tenofovir disoproxil fumarate-emtricitabine should be taken daily [Truvada/TenvirEM 200 mg/300 mg Tablet: Emtricitabine (200mg) + Tenofovir disoproxil fumarate (300mg)]

Post exposure prophylaxis X 28 days: 

1.    Viraday  or viropil: Emtricitabine (200 mg) + Tenofovir disoproxil fumarate (300 mg) + Efavirenz (600 mg)

2.    Viropil: Dolutegravir (50 mg) + Lamivudine (300 mg) + Tenofovir disoproxil fumarate (300 mg)

3.    Tenofovir disoproxil fumarate-emtricitabine plus one of the following: Raltegravir (Isentress) 400 mg twice daily or Dolutegravir (Instgra) 50 mg once daily

Take home points

• Treatment with three drugs in one pill, taken life long
• Pre exposure prophylaxis with two drugs taken daily
• Post exposure prophylaxis with 3 drugs taken for 28 days started within 3 days

Dr KK Aggarwal

Padma Shri Awardee

President Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

The first 2-drug complete regimen for HIV-infected adults who have never received ART

Dolutegravir and lamivudine have been approved by the US FDA as the first fixed-dose, complete regimen for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults with no antiretroviral treatment history and with no known or suspected substitutions associated with resistance to the individual components of the drug.

Currently, the standard of care for patients who have never been treated is a 3-drug regimen.

With this approval, patients who have never been treated have the option of taking a two-drug regimen in a single tablet while eliminating additional toxicity and potential drug interactions from a third drug.

Patients infected with both HIV and hepatitis B should add additional treatment for their hepatitis B or consider a different drug regimen.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Dengue patients should defer blood donation for up to 6-12 months post-infection

Should screening for dengue be mandatory before blood transfusion?

I recently came across a story in The Muscat Daily (Jan. 23, 2019) which said “the Ministry of Health (MoH) and the Department of Blood Banks Services in Oman have announced on their Twitter accounts that “those affected by dengue virus will not be allowed to donate blood for six months”. Dengue cases are being reported in the country. The latest figures by the Ministry of Health revealed that until January 22, there were 52 recorded cases of dengue fever. In a statement, MoH said, “As a precautionary measure to prevent the spread of the infection, residents and citizens of the dengue-affected areas will also not be allowed to donate blood for 28 days.”  According to the Ministry, this is being put in place to help “prevent others from contracting the disease”.

Travel is a risk factor for spread of any infectious disease. With increasing travel, there is a chance of the disease appearing in another part of the country or the globe, where it did not occur previously. Consequently, the prevalence of dengue has increased several-folds across the world.

The dengue virus was recognized as a transfusion-transmitted pathogen in 2008 (World J Virol. 2015; 4(2):113-23). Chikungunya virus is also a transfusion-transmissible infection, as per the World Health Organization (WHO).

Since then, there has been concern about the risk of transmission of dengue via blood transfusion. Dengue virus becomes a blood-borne pathogen during the period of viremia, which coincides with the febrile period (World J Virol. 2015; 4(2):113-23).

 “In 2009, the American Association of Blood Banks placed dengue virus in the highest category of emerging infectious agents for their potential impact on transfusion recipient safety for the next years in North America” (World J Virol. 2015; 4(2):113-23).

Although rare, cases of transfusion-transmitted dengue fever have been reported. So far, five cases of transfusion-transmitted dengue, including one case of dengue hemorrhagic fever, have been formerly documented (World J Virol. 2015; 4(2):113-23).

Blood donors have been recognized as likely vehicles for transmission of the infection in endemic areas.

Dengue has become endemic in India, particularly in Delhi, where it has become a perennial infection.

In a study conducted to determine the prevalence of dengue virus infection in blood donors in a tertiary care centre, high seroprevalence (58%) of dengue infection in healthy asymptomatic blood donors was found; but, no active viremia was detected (J Clin Diagn Res. 2016;10(10): DC08–DC10). 

Seroprevalence is still a risk to blood safety and is a potential source for transfusion-transmitted infections.

NACO National Blood Transfusion Council “Guidelines for Blood donor selection and Blood Donor Referral 2017” recommend that blood donation should be deferred for 6 months following full recovery in case of history of dengue or Chikungunya. A person who has visited a Dengue and/or Chikungunya endemic area is deferred for 4 weeks following return from the endemic area if no febrile illness is noted.

In its 2012 “Guidelines on Assessing Donor Suitability for Blood Donation”, the WHO also recommends that individuals with a history of dengue or chikungunya virus in endemic areas should defer for 6 months following full recovery from infection. It further says that individuals who have visited an area endemic for dengue or chikungunya should defer for 28 days following return. And, those who have suffered a febrile illness during or following return from an endemic region should defer for 6 months following full recovery from infection

Dr NK Bhatia, Medical Director, Mission Jan Jagriti Blood Bank is a renowned name in blood banking with more than three decades of experience the field. According to Dr NK Bhatia, “Dengue patients are not allowed to donate blood for one year after treatment. If there is a history of blood/blood products transfusion, the same deferral period applies. This is also true for Chikungunya patients. Any person who has a ‘normal’ viral fever is not allowed to donate blood for 7 days after the active phase is over. Some extend this duration to one year.”

Hence, a medical history becomes very important when assessing eligibility of a prospective blood donor.

Always ask a history of dengue/Chikungunya, history of blood/blood product transfusion and history of any viral fever.

Dengue patients should defer blood donation for up to 6-12 months post-infection.

But, a question then arises “Should screening for dengue be mandatory before blood transfusion as is for hepatitis B virus, hepatitis C virus, HIV, syphilis, malaria” as many dengue patients go undetected in acute febrile illness?

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

For HIV, undetectable is equal to untransmittable

The National Institutes of Health (NIH) has said that the Undetectable = Untransmittable (U=U) concept for HIV is a scientifically sound concept. Officials from NIH’s National Institute of Allergy and Infectious Diseases (NIAID) have reviewed results from large clinical trials and cohort studies for U=U, which validate the concept, in an article published in JAMA, Jan. 10, 2019.

U=U means that people living with HIV who have achieved and maintained an undetectable viral load (less than 40 copies in one ml of blood)) by taking and adhering to antiretroviral therapy (ART) as prescribed cannot sexually transmit the virus to others.  The U=U initiative was launched in 2016 by the Prevention Access Campaign with the goal of ending the HIV/AIDS pandemic as well as HIV-related stigma. As a prevention strategy, this is often referred to as Treatment as Prevention

The landmark NIH-funded HIV Prevention Trials Network (HPTN) 052 clinical trial showed that no linked HIV transmissions occurred among HIV serodifferent heterosexual couples when the partner living with HIV had a durably suppressed viral load. These findings were further confirmed by the PARTNER (1 and 2) and Opposites Attract studies, which extended these findings to male-male couples.

Validation of the HIV treatment as prevention strategy and acceptance of the U=U concept as scientifically sound have numerous behavioral, social and legal implications, says NHI.

U=U can help control the HIV pandemic by preventing HIV transmission, and it can reduce the stigma that many people with HIV face. The success of U=U as an HIV prevention method depends on achieving and maintaining an undetectable viral load by taking ART daily as prescribed. 

Implementing programs that help patients remain in care and addressing the barriers to daily therapy can enhance the overall success of U=U.

In September 2017, the Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention (CDC) has also said that “people who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner”.

(Source: NIH)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

HIV self-testing as a harm reduction strategy to prevent HIV/AIDS

The acquired immunodeficiency syndrome (AIDS) epidemic has had a devastating impact on human health from the time it was first reported in 1981 in the United States. Characterized by fear and ignorance, AIDS took a heavy toll of life in the initial years. The numbers were escalating and death was certain with no effective treatment available at that time. And, many died undiagnosed.

Significant progress has been made since then. While antiretroviral therapy (ART) has improved survival as well as the quality of life of people living with HIV, much more needs to be done.

A new report from UNAIDS “Knowledge is power - Know your status, know your viral load” shows that intensified HIV testing and treatment efforts are making a difference and are accessible to a greater number of people living with HIV. In 2017, three quarters of all people living with HIV (75%) knew their HIV status, compared to just two thirds (67%) in 2015, and 21.7 million people living with HIV (59%) had access to antiretroviral therapy, up from 17.2 million in 2015. However, the report also shows that about 9.4 million people living with HIV do not know they are living with the virus. It is this percentage of people living with HIV that need to be reached.

In 2014, UNAIDS set a treatment target of “90-90-90” to help end the AIDS epidemic by the year 2020. The aim is that 90% of all people living with HIV will know their HIV status, 90% of all people diagnosed with HIV will receive sustained ART and 90% of all people receiving ART will have durable suppression.

One of the biggest barriers to HIV testing is the fear of stigma and discrimination, which deters many from visiting the testing centers. Fear of being seen visiting the test centers, fear of the diagnosis itself and if diagnosed, fear that this information could be shared with their family, friends, or others are factors because of which people are afraid and hesitant to seek HIV testing.

Unless the uptake of HIV testing is increased, achieving the target of “90-90-90” will remain elusive. People with low access to testing facilities and those at higher risk that would otherwise not get tested are the ones that need to be encouraged to test themselves for HIV.

HIV self-testing has been suggested to improve HIV testing. It is a convenient testing approach for those who want to test themselves to know their HIV status in privacy. The WHO has strongly recommended “HIV self-testing” as an additional approach to existing HIV testing services. As stated by WHO, “HIV self-testing (HIVST) is an empowering and innovative way to reach more people with HIV and help achieve the first of the United Nation’s 90–90–90 targets – for 90% of all people with HIV to know their status by 2020”.

Under the National Strategic Plan on HIV/AIDS and Sexually Transmitted Infections (STI), 2017-24, the target by the year 2024, is to ensure that 95% of those who are HIV positive in the country know their status, 95% of those who know their status are on treatment and 95% of those who are on treatment experience effective viral load suppression.

India has a “Test and Treat Policy for HIV”, which means that anybody who is tested and found positive will get ART irrespective of CD count or clinical stage. India also has a “Viral Load testing” for all people living with HIV/AIDS to monitor the effectiveness of treatment of patients taking lifelong ART.

India, however, is in the process of implementing HIV self-testing. The policy on HIV rapid diagnostic tests self-testing is still under consideration. It should be implemented at the earliest.

As a harm reduction approach, HIV self-testing will help reach people who are at risk, including injecting drug users and may not otherwise test themselves for HIV. 

Knowing their HIV status will help them to start ART sooner to lead healthier lives and thence to improve their life expectancy and also reduce the risk of transmission of HIV.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

‘Kick & Kill”: Looking to cure HIV

Ever since the Human Immunodeficiency Virus (HIV) was discovered and identified as the cause of AIDS, scientists have been on the hunt for a cure, which is proving to be elusive.

The HIV virus remains concealed in the reservoir cells; for this reason, the HIV infection, which is in remission with antiretroviral drugs (ART), becomes active again as soon as ART is discontinued. Killing these latent reservoirs is therefore essential to achieving cure.

Scientists are better equipped today, both with knowledge and technology, which raises hopes of finding a cure.

One among the curative strategies, which has been explored the most, is the ‘kick and kill’ strategy. It is based on the premise that “kicking” (reactivating) the latent reservoirs would make the hidden HIV visible to the immune system, which then “kills” (destroys) the reactivated virus and thus eliminates the latent reservoir. However, the results of trials using the kick and kill strategy have not been very encouraging.

The RIVER study, the first proof of concept trial is the latest to investigate the “kick and kill” strategy in primary HIV infection using vorinostat as the “kick” and the boosted immune response, using a vector vaccine (HIV-specific) designed to train the immune system to recognize the reactivated virus as the “kill”. 

Vorinostat is a histone deacetylase (HDAC) inhibitor with antineoplastic activity. It is a gene stimulating drug, which enables inactive genes to switch back on, so the cells become active again. The study recruited 60 men recently diagnosed with HIV infection and had the virus under control with a minimum 12 weeks of ART before entering the study. The study participants were randomly assigned to ART alone or the “kick” and “kill” therapies (ARTVV) in addition to ART, at six sites in the UK.

First, the vaccine was administered in two doses, one at baseline and second, 8 weeks later. Then vorinostat was administered as one dose every three days for the next 30 days after week eight.

The findings of the randomized controlled trial were presented at the recently concluded International AIDS Society's annual meeting in Amsterdam, Netherlands (AIDS 2018). But, the results were not very encouraging. Despite evidence of strong vaccine-induced HIV-specific T-cell immunity (increased number of HIV-specific CD4 and CD8 cells) and vorinostat activity (increase in HIV gene expression), there was no impact on measures of HIV reservoir compared to ART alone. They did not reduce the cells containing HIV DNA. Those who had received the kick and kill drugs in addition to ART had similar levels of infected reservoir cells than those who were given only the standard ART therapy.

Professor Sarah Fidler of Imperial College London and Chief Investigator of the study said: "Finding an HIV cure means orchestrating a lot of things. We have to generate new ideas and turn them into trials that will give meaningful results, we have to agree what research tests will tell us whether things are working or not, we need to very carefully monitor study participants and most importantly we need to make sure any trial intervention is safe. RIVER achieved all these things but sadly not the evidence of a possible HIV cure yet.”

The reasons for failure of the ARTVV regimen to reduce the latent reservoir are being examined. “The important thing to realise is that despite these disappointing results, it does not mean that the basis of the approach is wrong,” said Professor John Frater of the University of Oxford, who is the co-principal investigator.

(Source: Science Daily)

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Homosexual relationships do not lead to STDs like AIDS: SC

Excerpts from TOI report

The Victorian-era morality, prohibitions, unsafe sex and living in denial have led to the spread of sexually transmitted diseases like AIDS and it cannot be blamed on homosexual relationships, the Supreme Court on Tuesday said while observing the sexual intercourse itself should not be seen as a crime. The apex court termed the prohibitions on acts like prostitution and homosexual relationships as one of the causes for the spread of STDs and said, "If you licence prostitution, you control it. If you shove it under the carpet, owing to some Victorian-era morality, it will only lead to health concerns".

A five-judge Constitution bench was not in agreement with the submissions of the lawyers favoring retention of section 377 in the IPC that the homosexual relationships have led to spread of AIDS.

"The cause of sexually transmitted diseases is not sexual intercourse. But unprotected sexual intercourse. A village woman may get the disease from a husband who is a migrant worker," the bench said. "This way you would want to make sexual intercourse itself a crime."

"We would not wait for the majoritarian government to enact, amend or not to enact any law to deal with violations of fundamental rights," the bench said and made clear that it may strike down a law if fundamental rights are infringed.

“Sexual orientation is of abstract nature and such an abstract concept cannot be read into Article 15 and moreover, the term sexual orientation has not been defined either in the Constitution or in any other statute”.

The bench said its NALSA verdict recognized transgender as a gender besides male and female.

The European Human Rights court has held that "the right to marry is not a conventional right".

The court reserved its verdict after lawyers concluded their arguments in the case.

The National Legal Services Authority (NALSA) v. Union of India is a landmark decision by the Supreme Court of India, which declared transgender people to be a 'third gender', affirmed that the fundamental rights granted under the Constitution of India will be equally applicable to transgender people, and gave them the right to self-identification of their gender as male, female or third-gender. The court also held that because transgender people were treated as socially and economically backward classes, they will be granted reservations in admissions to educational institutions and jobs.

MEDtalks

Sexual orientation is generally thought of as having three components: identity, behavior, and desire. "Gay" is generally used to describe how people identify themselves, while "men who have sex with men" (MSM) describes a behavior. MSM may identify themselves as gay, bisexual, queer, same-gender loving, or heterosexual. Some who are just beginning to come out may experience a desire to be intimate with other men, but may not yet have been sexually active with men or even identify as being gay. Some MSM do not even regard sex with other men as sexual activity, a term they reserve for sexual relations with women.

Gay men are at higher risk of human immunodeficiency virus (HIV) and other sexually transmitted infections. According to the CDC, 66% of new cases of HIV in the US in 2011 were in men who have sex with men (MSM), including MSM who use injectable drugs. They are more likely to attempt suicide and be homeless. Use of tobacco, alcohol, and other drugs are higher in them. Isolation and lack of supportive services are further barriers to health, especially in older gay men.

For effective HIV prevention, the CDC recommends that

·         Sexually active MSM (patient or his sex partner[s] have more than one sex partner since the patient's most recent HIV test) should be tested at least annually for HIV and other STIs.

·         Sexually active MSM should practice safe sex by choosing less risky behaviors, using condoms consistently and correctly if they have vaginal or anal sex, reducing the number of sex partners, and, if HIV-positive, letting potential sex partners know their status.

·         For some MSM at high risk, taking post-exposure prophylaxis (PEP) can reduce risk.

·         For sexually active MSM at substantial risk, pre-exposure prophylaxis (PrEP) is recommended as one option.

·         Health care providers and public health officials should ensure that:

o    Sexually active, HIV-negative MSM are tested for HIV at least annually (more frequent testing may be recommended e.g., every 3 to 6 months)

o    HIV-negative MSM who engage in unprotected sex receive risk-reduction interventions

o    HIV-positive MSM receive HIV care, treatment, and prevention services

·         Universal screening: HIV screening has long been a core prevention strategy.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

National IMA (membership 2.2 lacs) and eMedinewS (readership 1 lac) recommendations to Justice Verma

1. The word penis should not be used (use male sex organs) anywhere in the law

2. The work vagina, labia majora should not be used anywhere in the law (Female sex organs)

3. Under the influence of alcohol and drugs the punishment should be different and treatment added. For rarest of the rare case death sentence can be added. People with abnormal sexual urges should be treated.  

4. We must sensitize the parents, teachers and schools to identify red flag signals of an abnormal personality trait in children (present in up to 10% of children) so that they do not indulge in sexual offences later

5. Chemical castration is not acceptable to medical profession, is not safe, not health friendly is temporary and lead to corruption

6. Medical profession should help training all policemen in CPR and first aid

7. Every PCR van should be a mini ambulance also. One can post a paramedic in it for RTA and assault cases

8. Private hospital should be allowed to examine rape victims and guidelines should be pasted in every Emergency room

9. We need to define, issuing of medical bulletin, guidelines

10. Transfer to other country there should be a clear cut national policy and decide by a panel of treating doctors in consultation with Govt. health officials

 11. Sick RTA or assaulted patients should b shifted to a nearby hospital (govt. or private) so that medical services are available within ten minutes and stabilized within one hour.

12. Forensic examination lab should be strengthened and should give results in time bound manner.

13. Most sexual assault cases occur in slum areas. Efforts should be made to create awareness in these areas

14. All accused should be compulsorily be tested for sexually transmissible illnesses and victims be considered for STI, HIV and pregnancy prevention treatments

15. All health care professionals to have compulsorily short term training in counselling, empathy, communication, etiquette as part of medical education.

Drafted by Dr KK Aggarwal for National IMA and eMedinews based on proceedings of a seminar organised by IMA and inaugurated by National President IMA, Dr K Vijaykumar.