A Different Kind of Disease

The unmet need in researching and preventing HIV and Toxoplasmosis co-infection

By David Miller and Chris Romano

The International AIDS Society (IAS) held the world’s largest scientific gathering on HIV science in Paris, France this year, a country where 37% of patients with AIDS have evidence of toxoplasmic encephalitis.

Toxo has been reported as the most common opportunistic infection in HIV/AIDS in developed countries and the most common cause of focal brain lesions, coma and death. It commonly causes encephalitis in HIV-postive patients and increases the risk of HIV Associated Neurological Disorders (HAND) by 60%.

HAND is becoming increasingly prevalent as Anti-Retroviral Therapy (ART) allows HIV patients to live longer lives.  Several poster sessions at IAS 2017 discussed the issue of HAND.

Ei Kinai from the National Center for Global Health and Medicine in Tokyo, Japan presented on The Impact of Age and Time of Disease on HAND.  The study concluded that, “Older patients are more likely to have neurocognitive decline at early stages of HIV infections.”  It is also known that the prevalence of Toxo increases with age, an aspect that was not addressed in the study.

Galia Manuelle Aurora Santos from Lausanne University Hospital Center in Lausanne, Switzerland presented on the link between depressive symptoms and HAND.  This study suggests that addressing depressive symptoms, especially in HIV positive-women, might potentially improve the neurocognitive outcome of HIV-positive  patients.  Toxo has been linked to depression in numerous studies.Vincent Senecal of the Centre de Recherche du CHU de Quebec, Centre de Recherche en Infectiologie, Quebec, Canada shed light on HAND pathogenesis by studying the interactions of HIV with the anti-inflammatory chemokine, fractalkine (FKN). The results indicated that HIV reduced FKN receptor expression in microglia/macrophages which could have important implications in chronic inflammation and immune activation for HAND.  It has been found in separate studies that Toxo also down-regulates FKN after 24 hours of infection.

HAND continues to be a major concern in HIV patients and the connection between HAND and toxo is an understudied issue that may help to better understand and potentially treat HAND. New studies to determine if toxo has a causative effect contributing to neurocognitive decline in people living with HIV are essential.

Toxo infects approximately 1.1 million people each year in the United States. The global prevalence is estimated between 2 and 3 billion and there is no cure.  Acute infection in the immune compromised is often deadly if not aggressively treated with Pyrimethamine (Daraprim).   In 2014, the CDC designated Toxo a Neglected Parasitic Infection (NPI), targeting it for public health action based on the number of people infected and the severity of the disease.  Less than a year later, Martin Shkreli, then CEO of Turing Pharmaceuticals, acquired the rights to Daraprim and raised the price of the now 64 year old drug 5000%, a notorious move that increased an annual prescription to $634,500 for patients weighing more than 60 kilograms (132 pounds).

Without an available cure and considering the unfavorable treatment options at hand, our only immediate hope to alleviate the burden of toxo is to prevent human exposure to the offending pathogen causing the initial disease.

Toxo can only complete its life cycle and produce infectious spores on cat feces.  Most people and animals become infected by unknowingly ingesting or inhaling these spores which makes cleaning a cat’s litter box a high-risk activity, particularly to those who are immune- compromised. Simple precautions should be taken that can eliminate the risk of toxo infection.

Toxo is also transmitted by consuming the raw or rare meat of previously infected animals and is a leading cause of death from foodborne illness in the United States.  The general public is warned of toxo risk by the mandated menu advisory, “Consuming raw or undercooked meats, poultry, seafood, shellfish, eggs or unpasteurized milk may increase your risk of foodborne illness,”   But public awareness on how to prevent toxo infections is otherwise extremely limited.

With more than one third of the U.S population sharing their homes with pet cats, the responsibility to provide the warnings and resources necessary to protect the general public from the burdens of toxo and create a safer environment for both humans and cats, should be a high priority of our public health d healthcare systems.

viable solutions to reducing the risk of toxo are essential. One such alternative to using masks and gloves when changing kitty litter is a self-contained cat waste disposal system (created by Toxoplasmosis Solutions, an enterprise of BetterBox) which allows cat owners to safely contain and dispose of domestic cat waste without exposing themselves or their environment to toxo’s infectious spores. Additional tools that the public can utilize including public service announcements on how to properly handle and prepare raw meet, are needed.

Toxo’s life cycle is dependent on cat waste contaminating the environment of its future hosts.  Considering that the majority of cats in the U.S. are domesticated and living in human homes, mechanically blocking the life cycle of this devastating disease by implementing responsible cat waste disposal procedures is an effective option.

Legislators in the U.S. need to be encouraged to develop a national toxoplasmosis bill supporting the additional research, education, prevention, and treatment efforts. The latest scientific findings regarding “latent” toxo along with the compelling epidemiology to inform legislators, public health officials, and health insurance providers that an investment towards designing public awareness has great potential to reduce healthcare costs and disease burden in the United States and globally.

 

 

The Eastern View from AIDS 2018

By David Miller and Chad Johnson

Many AIDS 2017 attendees in Paris were disappointed by the neglect of a timely, critical focus on the HIV challenges in Venezuela caused by the abject failure of governance, human rights, and the rule of law in Caracas.  With the country falling apart and people unable to obtain essential HIV medications and basic medical supplies, the lack of a concerted effort to address this urgent human tragedy at AIDS 2017 seemed like an astounding failure of the most powerful gathering of stakeholders in the epidemic.  However, an equally pressing dynamic has existed for years without mainstream media coverage in many countries in Eastern Europe and Central Asia (EECA).  While not making the daily headlines, the EECA region has the highest new HIV infection rate in the world at 57% between 2010 and 2015 according to AVERT, a statistic highlighted at the AIDS 2017 teaser session on the upcoming 22^nd International AIDS Conference in Amsterdam, Netherlands in July 2018 (AIDS 2018).

The AIDS 2018 session emphasized that one of Amsterdam’s top five objectives is to change the dynamic in the EECA where governments, institutions, orthodox religions, society, law enforcement and criminality, and international organizations fail vulnerable populations.  Session participants noted that this EECA problem was on the agenda during the 19^th IAC in Vienna in 2010, a conference now deemed a failure in this regard.  Leading up to AIDS 2010, the WHO reported that the epidemic in Eastern Europe “… can be ascribed to government intransigence, public ignorance and the criminalization of risky behaviors, compounded by poverty, social exclusion and political and economic turmoil.”  These conditions have not significantly changed in Eastern Europe and continued to be mirrored in Central Asia.

Consequently, AIDS 2018 Local Co-Chair Dr. Peter Reiss of Amsterdam and International Co-Chair Dr. Linda Gail-Bekker of Cape Town, South Africa committed to shine a spotlight on people left behind in the international response to the AIDS epidemic and to prompt a vigorous discussion about the reasons that the EECA region is an outlier in the progress seen around the world.  The theme of AIDS 2018, “Breaking Barriers Building Bridges,” speaks to some of the unique contributing factors beyond unsafe sexual practices, including language, culture, lack of human rights and freedom of information, and “relative” prosperity (and with it, non-qualification for various international assistance programs).  Additional factors on the rise in the EECA region include IV drug use in countries disapproving of needle-exchange programs, migration of female sex workers who are shamed into the shadows by conservative societies, and the refugee crisis and its health consequence.

The organizer of the session, the Dutch Ministry of Foreign Affairs, represented by Mr. Lambert Grijus, the Dutch Ambassador for Sexual and Reproductive Health & Rights and HIV/AIDS, articulated rights- and community-based approaches to more effectively reach key populations in the EECA region, along with putting mechanisms in place to hold politicians accountable in regional and international diplomatic settings for shortcomings in HIV-related awareness, funding and policy.  Dr. Michel Kazatchkine, former Director of the Global Fund and currently the UN Secretary-General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia, also underscored the importance of aggressive work with top-level politicians as key to breaking the log jam in the region.  Unless governments acknowledge and take ownership of the growing HIV problem, outside efforts will continue to fail.  In some EECA nations, leaders are in denial that HIV/AIDS even exist in their countries – typifying the difficulties that stand between an increasing epidemic and effective solutions.

On top of government inaction and denial, several avenues of international support are not available as policy enticements since median incomes disqualify funding and assistant for many EECA countries – incomes that are by no means truly prosperous.  Traditional and orthodox populations in rights-limited societies add to the slow demand for and pace of change.  Communication and the free flow of HIV-related information are limited, and a lack of historical commitment to Russian language-based prevention and treatment programs is recognized as a problem for much of the EECA region.

The eastern view from Amsterdam is gloomy but there are glimmers of light.  AIDS 2018 will lead to critical analysis of potential solutions for the epidemic in the EECA.  However, session participants emphasized that the HIV/AIDS community cannot wait until July 2018 to make progress in EECA nations:  lives are at stake, and change is needed now

HIV drug used to reverse effects of virus that causes cervical cancer

A commonly-used HIV drug has been shown to kill-off the human papilloma virus (HPV) that leads to cervical cancer in a world-first clinical trial led by The University of Manchester with Kenyatta National Hospital (KNH) in Nairobi.

Drs Ian and Lynne Hampson, from the University’s Institute of Cancer Sciences and Dr Innocent Orora Maranga, Consultant in Obstetrics and Gynaecology at KNH in Nairobi examined Kenyan women diagnosed with HPV positive early stage cervical cancer who were treated with the antiviral HIV drug lopinavir in Kenya.

Walgreens Expands Access to Pharmacist-Led Hepatitis C Care as Treatments Advance

More than 100 Walgreens Pharmacies Designated Hepatitis C-Specialized to Meet Projected Patient Care Management Needs and Improve Medication Adherence.

With new advances in treatment therapy now available for hepatitis C patients, Walgreens (NYSE:WAG) (Nasdaq:WAG) today announced it is expanding access to Walgreens Connected Caresm hepatitis C program through its more than 100 hepatitis C-specialized pharmacies. Walgreens Connected Care is an education and support plan designed to help patients achieve a sustained virologic response (SVR) and improved quality of life through medication adherence.

UNAIDS and Lancet Commission to put forward recommendations on AIDS and global health for the post-2015 debate

The UNAIDS and Lancet Commission: Defeating AIDS – Advancing global health, reconvenes in London for final meeting on the future of HIV and global health.

LONDON/GENEVA, 13 February 2014—The UNAIDS and Lancet Commission: Defeating AIDS – Advancing global health is meeting in London on the future of AIDS and global health in the post-2015 era—the recommendations will be published in The Lancet later this year.