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RNA Testing for HIV Instead of Antibody Testing Could Detect Early Stage of HIV Infection And Would Likely Improve Prevention AND Allow for Early HAART' Could it Prevent Accelerated Aging?
  Reported by Jules Levin
Numerous studies have looked at HAART in acute in HIV infection to find little benefit in terms of longer term improved undetectability rates. HOWEVER, recent concerns that HIV accelerates aging raises the question again if HAART during the very early stages of HIV infection would be beneficial in the very long term in terms of slowing accelerated aging in HIV+ individuals, and these studies have not been done. What do I mean? In the past 2 years we have become acutely aware that rates of non-AIDS complications (liver disease, cognitive impairment/brain dysfunction, cardiovascular disease, bone disease, renal disease) are increased and are causing premature deaths. It looks like HIV itself plays a serious role in this by leading to senescent T-cells soon after HIV infection (prematurely aging T-cell repertoire), leading to ongoing inflammation which apparently can occur despite undetectable viral load, and hyper activation of the immune system which also appears to occur despite undetectable viral load. Dealing with these questions related to aging has become THE QUESTION of the year.
The NIH has issued 3 RFPs to fund aging research and this is or should be the most discussed subject in the HIV field. Some clinicians and clinical researchers do not appear very interested or knowledgable about the question as reflected by a meeting I just attended on Aging & HIV where many clinical researchers did not appear to me to really understand the imperative of this question or just had no ideas about it. But in real research science circles like at Alan Landay's Immunology Lab in Chicago, at NIAIDS, in the MACS Study Group, at the Immunology Lab at USC or UCLA they are conducting REAL aging with HIV basic science studies to examine these questions--to understand the mechanisms and eventually to perhaps find interventions. Granted, I think finding interventions will NOT be easy, but unless we focus on this we certainly will not.
THIS IS the number one issue for patients in the USA and Western World with HIV and certainly for those who have been on HAART and moreso for those aging, past 50 yrs old. Soon, death rates will dramatically increase, in my opinion, due to increased rates of non-AIDS comorbidities. HIV+ indviduals aging past 50 yrs tend to be more frail as evidenced by a published study finding frailty significantly increased in HIV+ individuals as they age compared to HIV-negative individuals.
Osteopenia rates are 60% in HIV at the average age of 45 yrs in cohort studies, and fractures increase mortality in the aging HIV-negative population, and a recent study by Grinspoon found fracture rates were HIGHER among HIV+ vs HIV-negs. This leads me back to the original point. Is there a benefit to starting HAART immediately after infection? I think we would need to do a study to see if you could reverse senescent T-cell development by this, so we would have to understand perhaps when senescense sets in and is it reversible. Does senescence begin upon immediate infection or does it ocurr after 1 year of infection? These are important questions.
RNA Tests for New H.I.V. Infection Not Widely Adopted: "would encourage early care and effective prevention".....
"And if everyone were tested, the stigma surrounding AIDS testing might decrease"..... 'routinization" of AIDS within the range of infectious diseases; Dr. Anthony Fauci..."Treatment," he says, "would be prevention."

Published: April 30, 2009
In December 2008, after a weekend of sex fueled by methamphetamine, Chris, a San Francisco man in his early 30s, sought out testing for sexually transmitted diseases at Magnet, a clinic serving homosexual men in the city?s Castro neighborhood.
Tim Ryan, RN, clinical supervisor at Magnet in San Francisco, performs a blood draw -- the method used to collect specimens for HIV RNA testing.
Staff members tested him for H.I.V.twice: first with a standard rapid test, which detects H.I.V. antibodies in saliva or a drop of blood, then with a blood test for genetic traces of the virus itself.
Although the antibody test can deliver immediate results, it is not likely to identify an infection that has occurred in the past month. The genetic test, which looks for bits of the virus?s ribonucleic acid, or RNA, can identify infections in a week to 10 days. Chris, who asked that his full name not be used, was told that his antibody test was negative. But his RNA test was positive, making him one of the few whose diagnosis came in the acute, or primary, phase of infection, when the virus is replicating aggressively but the body has not yet mounted an effective immune response. Many public health officials and AIDS experts increasingly see identification of the newly infected as an important next step in controlling the spread of H.I.V., the virus that causes AIDS. Yet the RNA test, the only one capable of detecting the newest infections, has not been widely adopted for this purpose.
"People with acute infection have more virus in the blood, and if they're unaware they're infected, they're more likely to engage in risky behavior," said Dr. Kenneth Mayer, a professor of medicine at Brown University and a leading AIDS researcher.
Finding those with new infections sooner and providing counseling will help prevent them from infecting others, Dr. Mayer said. As it stands, studies suggest that the recently infected could be the source of 10 percent to 50 percent of all new H.I.V. transmissions.
"We have a serious ongoing problem of H.I.V. transmission that hasn?t been adequately addressed," said Dr. Jeffrey Klausner, director of S.T.D. prevention at the San Francisco Department of Public Health.
The Centers for Disease Control and Prevention has conducted pilot studies of RNA testing in some cities, but current national guidelines focus on more widespread antibody testing to identify some of the estimated 250,000 Americans who are infected but do not know it. Routine RNA testing has been tried rarely, in part because it is expensive, involves drawing blood and complicated laboratory work, and does not provide immediate results.
But health departments in North Carolina and San Francisco have used the tests in some settings for several years, reducing costs by pooling many blood samples and testing them together. Officials there have reported finding dozens of cases of acute infection that were not detected by the standard test, and they have advocated for much wider use of the RNA test.
The Magnet clinic began its RNA testing program last year to serve gay men who engage in unprotected sex and are in social and sexual networks at the highest risk of acquiring H.I.V. "Early detection is a prevention strategy," said Judy Auerbach, public policy director of the San Francisco AIDS Foundation, which runs the clinic.
Chris, the San Francisco man whose infection was diagnosed with an RNA test, said the early diagnosis had allowed him "to be more proactive, to get right on it at the start and feel a little bit more in control."
Reduction of H.I.V. transmission rates has taken on renewed urgency. Last year, the disease control agency raised its estimate for annual new H.I.V. infections to 56,000, from 40,000. In 2008, the agency reported that from 2001 to 2006, H.I.V. diagnoses increased annually by 15 percent among young African-American men who have sex with men.
A less expensive alternative to the RNA test may not be far away. The centers recently began a study to compare RNA testing with an advanced version of the standard test, which is easy to administer and can detect a substance produced by the virus in its early stages.
The newest test, called an antibody-antigen test, appears able to identify 85 percent of the acute H.I.V. infections picked up by the RNA test and could be commercially available next year, agency officials said.

The Invisible Epidemic
Wash Post
By Michael Gerson
Friday, May 1, 2009
As I was waiting for the results of my AIDS test, the health lecture from my counselor Anthony was calm, explicit and, um, informative. The five bodily fluids that can transmit the HIV virus. The proper way to open a condom package to avoid rips (I did it all wrong). Certain uses for Saran Wrap not specified by the manufacturer.
An AIDS clinic in Washington -- a new ground zero in the American AIDS crisis -- is no place for the squeamish. The test itself looks like a pregnancy test, in its small, white, plastic momentousness. The swab at the end is run across the gum line; no blood is drawn. The results take about 20 minutes and are 99.1 percent accurate.
I was visiting Unity Health Care in Ward 7, an outpost of tidy medical professionalism in a poor section of the city. Here the talk of epidemics has nothing to do with swine flu. The Centers for Disease Control and Prevention describes a health epidemic as "severe" when more than 1 percent of people in a geographic area are infected. The HIV infection rate in Ward 7 is at least 2.4 percent -- higher than the national rate in Ethiopia, Ghana or Burundi. Among 40- to 49-year-olds in the District, 7.2 percent are HIV-positive.
If 7.2 percent of all 40-somethings in America were infected with anything, there would be no other topic of national discussion -- every alarm would ring, every clock would stop. In this case, the victims are geographically isolated, often poor and thus largely invisible.
Unity Health Care provides services from dermatology to ophthalmology; due to stigma, few would come to a clinic that deals exclusively with HIV/AIDS. But Dr. Gebeyehu Teferi, the medical director of HIV services, sees the AIDS crisis in every form -- intravenous drug users, prostitutes, men who have sex with men, and middle-aged women shocked by their diagnosis and the infidelity of their partners. (Among African Americans in the District, the single largest method of transmission is heterosexual sex.) "There are late, full-blown cases coming into the emergency room," says Teferi. "People who say, 'I don't use drugs, or even drink.' They forget about the sexual part of it."
The staff at Unity recommends three changes to confront the epidemic. First, AIDS needs to be discussed at home. In prevention, there is no substitute for uncomfortable frankness. Neither self-interest nor morality is aided by ignorance.
Second, they argue for the "routinization" of AIDS within the range of infectious diseases. Because of its politically charged history, HIV infection is treated differently. A positive syphilis test, for example, is reported directly from the medical lab to the local health department. "If it is syphilis," says Teferi, "there is a knock on their door to get them into treatment. If it is HIV, no one talks to them." Third, testing needs to be broader. At Unity, they refer to HIV status as the "fifth vital sign" (after temperature, heart rate, blood pressure and respiratory rate). People who know their positive status are more likely to change their behavior and get treatment for opportunistic infections. Early treatment can also reduce the virus to a nearly undetectable level in the body, drastically lowering transmission from mothers to children during childbirth and between discordant couples (partners where one is HIV-positive and one is HIV-negative).
This raises an interesting prospect supported by Dr. Anthony Fauci, the director of theNational Institute of Allergy and Infectious Diseases. Developing an AIDS vaccine, he says, remains unlikely in the short term. But what if we were to begin treatment with AIDS drugs as soon as someone is diagnosed with HIV instead of waiting, as we now do, until later stages? Lower viral loads would inhibit transmission. "Treatment," he says, "would be prevention." According to the mathematical model Fauci has reviewed, the testing and treatment of 90 percent of those at risk could eventually eradicate -- not just control, but eradicate -- the disease in a geographic area.
The obstacles are immense. Would people take AIDS drugs when they still felt well? Would any community help promote testing on such a massive scale? Would it be cost-effective?
But even the attempt would have many good effects. It would encourage early care and effective prevention. And if everyone were tested, the stigma surrounding AIDS testing might decrease. It takes only 20 minutes.
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