Psychological and social problems in HIV infection: interviews with general practitioners in London.

OBJECTIVE--To assess current practice and opinions of general practitioners in London about managing psychological and social problems relating to HIV infection. DESIGN--A stratified random sample of general practitioners, including those with a range of experience of people with HIV infection, were interviewed by medically trained interviewers. SETTING--Doctor''s surgeries. PARTICIPANTS--270 General practitioners working within the area covered by London postcodes. RESULTS--Two thirds of doctors had treated at least one patient with HIV infection and described their work with these patients. General practitioners were counselling and educating many of their patients about AIDS and associated risk behaviours and were aware of the need for careful attention to confidentiality. Doctors with no experience of patients with HIV infection were often older, in singlehanded practice, less inclined to deal with drug abusers or to counsel their patients on risk behaviours, and more in favour of insurance companies'' policies towards people with HIV infection. CONCLUSIONS--General practitioners in London are quickly becoming involved in the care of patients with HIV infection and their relatives and friends. Many are counselling patients and testing for antibodies themselves and regard this as an integral part of their work. A considerable workload in primary care comprised patients who obsessively fear contracting HIV infection.     

Effects of Minority Stress,Group-Level Coping,and Social Support on Mental Health of German Gay Men

Objective

According to epidemiological studies, gay men are at a higher risk of mental disorders than heterosexual men. In the current study, the minority stress theory was investigated in German gay men: 1) it was hypothesized that minority stressors would positively predict mental health problems and that 2) group-level coping and social support variables would moderate these predictions negatively.

Methods

Data from 1,188 German self-identified gay men were collected online. The questionnaire included items about socio-demographics, minority stress (victimization, rejection sensitivity, and internalized homonegativity), group-level coping (disclosure of sexual orientation, homopositivity, gay affirmation, gay rights support, and gay rights activism), and social support (gay social support and non-gay social support). A moderated multiple regression was conducted.

Results

Minority stressors positively predicted mental health problems. Group-level coping did not interact with minority stressors, with the exception of disclosure and homopositivity interacting marginally with some minority stressors. Further, only two interactions were found for social support variables and minority stress, one of them marginal. Gay and non-gay social support inversely predicted mental health problems. In addition, disclosure and homopositivity marginally predicted mental health problems.

Conclusions

The findings imply that the minority stress theory should be modified. Disclosure does not have a relevant effect on mental health, while social support variables directly influence mental health of gay men. Group-level coping does not interact with minority stressors relevantly, and only one relevant interaction between social support and minority stress was found. Further longitudinal or experimental replication is needed before transferring the results to mental health interventions and prevention strategies for gay men.     

Attitudes towards HIV/AIDS among four year medical students at the University of Zagreb Medical School--better in 2002 than in 1993 but still unfavorable

Fourth-year medical students at Zagreb University School of Medicine were surveyed about their knowledge and attitudes regarding HIV/AIDS in 2002/03 and this was compared to a student generation studying during 1993/94. Results indicated that the 2002/03 students scored significantly higher then did 1993/94 students on knowledge, and attitudes towards HIV/AIDS. However, 84% of 2002/03 students believed that health care workers (HCW) have the right to know the HIV status of their patients, 50% would disclose the HIV status to another HCW against patient's wishes and only 35% believed that HIV testing should be voluntary. The following factors were independently associated with a more favorable attitude towards HIV/AIDS: less homophobia (beta = -0.37, p < 0.001), experience with HIV/AIDS patients (beta = 1.02, p < 0.001), better knowledge about transmission (beta = 0.18, p = 0.016), and 2002/03 academic year (beta = -1.45, p = 0.011). Despite improvements, some negative attitudes towards HIV/AIDS remained prevalent in 2002/03.     

Cost effectiveness analysis of early zidovudine treatment of HIV infected patients.

OBJECTIVE--To compare cost effectiveness of early and later treatment with zidovudine for patients infected with HIV. DESIGN--Markov chain analysis of cost effectiveness based on results of use of health care and efficacy from a trial of zidovudine treatment. SETTING--Seven Veterans Affairs medical centres in the United States. SUBJECTS--338 patients with symptomatic HIV infection and a lymphocyte count of 200 x 10(6) to 500 x 10(6) CD4 cells/l. INTERVENTIONS--Zidovudine 1500 mg/day started either at recruitment to the trial or when CD4 cell count fell below 200 x 10(6)/l. MAIN OUTCOME MEASURES--Health care costs and rates of disease progression between six clinical states of HIV infection. RESULTS--Patients given early treatment with zidovudine remained without AIDS for an extra two months at a cost of $10,750 for each extra month without AIDS (at 1991 costs). Cost effectiveness ratio was most sensitive to the cost of zidovudine and to the quality of life of patients receiving early treatment. At treatment of 500 mg/day the cost effectiveness ratio for early treatment was $5432 for each extra month without AIDS. Patients given early treatment experienced more side effects, and if their quality of life was devalued by 8% compared with patients treated later the two treatments were equivalent in terms of quality adjusted months of life without AIDS. CONCLUSIONS--Early treatment with zidovudine is expensive and is very sensitive to the cost of zidovudine and to potential reductions in quality of life of patients who experience side effects. Doctors should reconsider early treatment with zidovudine for patients who experience side effects that substantially compromise their quality of life.     

HIV,Disease Plague,Demoralization and ``Burnout': Resident Experience of the Medical Profession in Nairobi,Kenya

This paper describes the experiencesof physicians-in-training at a public hospitalin Nairobi, Kenya, where medical professionalspractice in an environment characterized byboth significant lack of resources andpatients with HIV/AIDS in historicallyunprecedented numbers. The data reported hereare part of a larger study examining ethicaldilemmas in medical education and practiceamong physicians in East Africa. Aquestionnaire and semi-structured interviewwere completed by fifty residents in fourmedical specialties, examining social andemotional supports, personal and professionalsources of stress, emotional numbing anddisengagement from patients and peers, andsymptoms of post-traumatic stress anddepression. The factors affecting residentwell-being are found in this study to be morecomplex than previous interviews suggested. This study highlights the fact that as a resultof working in an environment characterized by poor communication among hospital staff aswell as a lack of resources and high numbersof patients with HIV/AIDS, residents'perceptions of themselves – their technicalproficiency, their ability to care and feel forothers and themselves, and for some theirentire sense of self – are significantlyaffected. Also affected are the patients theywork to treat.     

National cross sectional study of views on sexual violence and risk of HIV infection and AIDS among South African school pupils

Objective To investigate the views of school pupils on sexual violence and on the risk of HIV infection and AIDS and their experiences of sexual violence.Design National cross sectional study.Setting 5162 classes in 1418 South African schools.Participants 269 705 school pupils aged 10-19 years in grades 6-11.Main outcome measure Answers to questions about sexual violence and about the risk of HIV infection and AIDS.Results Misconceptions about sexual violence were common among both sexes, but more females held views that would put them at high risk of HIV infection. One third of the respondents thought they might be HIV positive. This was associated with misconceptions about sexual violence and about the risk of HIV infection and AIDS. Around 11% of males and 4% of females claimed to have forced someone else to have sex; 66% of these males and 71% of these females had themselves been forced to have sex. A history of forced sex was a powerful determinant of views on sexual violence and risk of HIV infection.Conclusions The views of South African youth on sexual violence and on the risk of HIV infection and AIDS were compatible with acceptance of sexual coercion and “adaptive” attitudes to survival in a violent society. Views differed little between the sexes.     

Great Expectations: Teaching Ethics to Medical Students in South Africa

Many academic philosophers and ethicists are appointed to teach ethics to medical students. We explore exactly what this task entails. In South Africa the Health Professions Council's curriculum for training medical practitioners requires not only that students be taught to apply ethical theory to issues and be made aware of the legal and regulatory requirements of their profession, it also expects moral formation and the inculcation of professional virtue in students. We explore whether such expectations are reasonable. We defend the claim that physicians ought to be persons of virtuous character, on the grounds of the social contract between society and the profession. We further argue that since the expectations of virtue of health care professionals are reasonable, it is also sound reasoning to expect ethics teachers to try to inculcate such virtues in their students, so far as this is possible. Furthermore, this requires of such teachers that they be suitable role models of ethical practice and virtue, themselves. We claim that this applies to ethics teachers who are themselves not members of the medical profession, too, even though they are not bound by the same social contract as doctors. We conclude that those who accept employment as teachers of ethics to medical students, where as part of their contractual obligation they are expected to inculcate moral values in their students, ought to be prepared to accept their responsibility to be professionally ethical, themselves.     

Occupational HIV infection. Medical workers and HIV prevention

The analysis of the possibility of suffering injuries at a work place, their causes, the knowledge of HIV infection, attitude towards the infected person is presented. The work was carried out, starting from 1990. Every 2 years the anonymous questioning of members of the medical personnel of different specialties at medical institutions of different profile and level was carried out. Five questionings on injuries suffered during work, the knowledge of HIV infection and the attitude of members of the medical profession towards HIV-positive persons. In most cases injuries are inflicted by injection needles (79%), during operations (12%), by splinters of broken medical glassware and appliances (3%) and in other cases (6%). In 91% of cases injuries caused by needles occur in the process of placing caps on the needles. In the course of 9 years changes in the level of knowledge and the attitude towards HIV-infected persons occurred. Changes in the outlook and the knowledge of AIDS were due to the positive influence of intensive education directly at work places.     

Determinants of Clinician Knowledge on Aging and HIV/AIDS: A Survey of Practitioners and Policy Makers in Kampala District,Uganda

Objective

The HIV/AIDS epidemic has evolved with an increasing burden in older adults. We assessed for knowledge about aging and HIV/AIDS, among clinicians in Kampala district, Uganda.

Methods

A cross-sectional survey of 301 clinicians complemented by 9 key-informant interviews between May and October 2011. Data was analyzed by multivariable logistic regression for potential determinants of clinician knowledge about HIV/AIDS in older adults, estimating their adjusted Odds Ratios (aOR) and 95% confidence intervals (95% CI) using Stata 11.2 software.

Results

Two-hundred and sixty-two questionnaires (87.7%) were returned. Respondents had a median age of 30 years (IQR 27–34) and 57.8% were general medical doctors. The mean knowledge score was 49% (range 8.8%–79.4%). Questions related to co-morbidities in HIV/AIDS (non-AIDS related cancers and systemic diseases) and chronic antiretroviral treatment toxicities (metabolic disorders) accounted for significantly lower scores (mean, 41.7%, 95% CI: 39.3%–44%) compared to HIV/AIDS epidemiology and prevention (mean, 65.7%, 95% CI: 63.7%–67.7%). Determinants of clinician knowledge in the multivariable analysis included (category, aOR, 95% CI): clinician age (30–39 years; 3.28∶1.65–9.75), number of persons with HIV/AIDS seen in the past year (less than 50; 0.34∶0.14–0.86) and clinical profession (clinical nurse practitioner; 0.31∶0.11–0.83). Having diploma level education had a marginal association with lower knowledge about HIV and aging (p = 0.09).

Conclusion

Our study identified gaps and determinants of knowledge about HIV/AIDS in older adults among clinicians in Kampala district, Uganda. Clinicians in low and middle income countries could benefit from targeted training in chronic care for older adults with HIV/AIDS and long-term complications of antiretroviral treatment.     

Soluble mediators of inflammation in HIV and their implications for therapeutics and vaccine development

From early in the HIV epidemic it was appreciated that many inflammatory markers such as neopterin and TNF-α were elevated in patients with AIDS. With the advent of modern technology able to measure a broad array of cytokines, we now know that from the earliest points of infection HIV induces a cytokine storm. This review will focus on how cytokines are disturbed in HIV infection and will explore potential therapeutic uses of cytokines. These factors can be used directly as therapy during HIV infection, either to suppress viral replication or prevent deleterious immune effects of infection, such as CD4+ T cell depletion. Cytokines also show great promise as adjuvants in the development of HIV vaccines, which would be critical for the eventual control of the epidemic.     

Use of respondent driven sampling (RDS) generates a very diverse sample of men who have sex with men (MSM) in Buenos Aires, Argentina

Background

Prior research focusing on men who have sex with men (MSM) conducted in Buenos Aires, Argentina, used convenience samples that included mainly gay identified men. To increase MSM sample representativeness, we used Respondent Driven Sampling (RDS) for the first time in Argentina. Using RDS, under certain specified conditions, the observed estimates for the percentage of the population with a specific trait are asymptotically unbiased. We describe, the diversity of the recruited sample, from the point of view of sexual orientation, and contrast the different subgroups in terms of their HIV sexual risk behavior.

Methodology

500 MSM were recruited using RDS. Behavioral data were collected through face-to-face interviews and Web-based CASI.

Conclusion

In contrast with prior studies, RDS generated a very diverse sample of MSM from a sexual identity perspective. Only 24.5% of participants identified as gay; 36.2% identified as bisexual, 21.9% as heterosexual, and 17.4% were grouped as “other.” Gay and non-gay identified MSM differed significantly in their sexual behavior, the former having higher numbers of partners, more frequent sexual contacts and less frequency of condom use. One third of the men (gay, 3%; bisexual, 34%, heterosexual, 51%; other, 49%) reported having had sex with men, women and transvestites in the two months prior to the interview. This population requires further study and, potentially, HIV prevention strategies tailored to such diversity of partnerships. Our results highlight the potential effectiveness of using RDS to reach non-gay identified MSM. They also present lessons learned in the implementation of RDS to recruit MSM concerning both the importance and limitations of formative work, the need to tailor incentives to circumstances of the less affluent potential participants, the need to prevent masking, and the challenge of assessing network size.     

Peptide nucleic acids as epigenetic inhibitors of HIV-1

The advent of highly active antiretroviral therapy (HAART) was once perceived to havetransformed deadly HIV/AIDS into a treatable, chronic infectious disease. However, mountingevidence now suggests that the prevalence of multi-drug resistant HIV (MDR-HIV) infection issteadily rising among newly infected individuals in the HAART-experienced countries, raising aconcern for a future outbreak of MDR-HIV/AIDS. Our global fight against AIDS must include sustainedeffort to search and discover a new therapeutic modality for HIV infection. Of plausible viraltargets explored to date, HIV gene-targeting approach has not yet seen a considerable success invivo. The pursuit of anti-HIV gene intervention should include the identification of critical genetargets as well as the optimization of biomolecules that can effectively interact with theintended targets. Using unmodified peptide nucleic acids (PNA) as a biomolecular tool, we discovereda potentially critical HIV gene segment within gag-polencoding gene. Antisense PNA targetingthis specific region effectively disrupted a translation of HIV gag-polmRNA, abolishing thevirion production from chronically HIV-infected cells. This exemplifies the possibility that epigenic HIV inhibitors may be developed in the coming years, if emerging novel technologies permitsufficient and stable in vivo delivery of PNA or other similarly effective biomolecules.     

General practitioners' attitudes towards AIDS and their perceived information needs.

A short questionnaire on general practitioners'' self perceived and actual knowledge of AIDS and their attitudes to the illness was sent to 1824 general practitioners throughout the United Kingdom. The rate of response was 70%. Women doctors, those who trained overseas, and those who were married tended to have less positive attitudes towards patients with HIV and AIDS, whereas younger doctors, trainers, and members of the Royal College of General Practitioners were more understanding, better informed, and had more positive attitudes. Doctors with the least knowledge about HIV and AIDS and the most negative attitudes towards the illness would benefit from further education, which would be most effectively delivered through the professional journals, the Department of Health and the charitable AIDS organisations.     

Peptide nucleic acids as epigenetic inhibitors of HIV-1

Summary The advent of highly active antiretroviral therapy (HAART) was once perceived to have transformed deadly HIV/AIDS into a treatable, chronic infectious disease. However, mounting evidence now suggests that the prevalence of multi-drug resistant HIV (MDR-HIV) infection is steadily rising among newly infected individuals in the HAART-experienced countries, raising a concern for a future outbreak of MDR-HIV/AIDS. Our global fight against AIDS must include sustained effort to search and discover a new therapeutic modality for HIV infection. Of plausible viral targets explored to date, HIV gene-targeting approach has not yet seen a considerable success in vivo. The pursuit of anti-HIV gene intervention should include the identification of critical gene targets as well as the optimization of biomolecules that can effectively interact with the intended targets. Using unmodified peptide nucleic acids (PNA) as a biomolecular tool, we discovered a potentially critical HIV gene segment within gag-pol encoding gene. Antisense PNA targeting this specific region effectively disrupted a translation of HIV gag-pol mRNA, abolishing the virion production from chronically HIV-infected cells. This exemplifies the possibility that epigenic HIV inhibitors may be developed in the coming years, if emerging novel technologies permit sufficient and stable in vivo delivery of PNA or other similarly effective biomolecules.     

HIV and measures to control infection in general practice.

OBJECTIVE--To assess the impact of HIV on procedures to control infection in general practices. DESIGN--A postal questionnaire survey. SETTING--General practices throughout Britain. SUBJECTS--5359 General practitioners, 3429 (63.9%) of whom returned the questionnaire. MAIN OUTCOME MEASURE--Response to questionnaire on knowledge about HIV and policies for controlling infection. RESULTS--Most doctors (2018) had started to wear gloves when taking blood. Almost half (1510) had not resheathed needles previously but a further 776 had adopted this policy because of HIV. Over half of the doctors did not know or were unsure about the risk of infection from needlestick injuries, and 1759 had no practice policy for controlling infection. CONCLUSIONS--Many doctors are uncertain about measures to control infection in general practice. More information and advice are needed to help doctors develop policies to protect patients and staff.     

Peptide nucleic acids as epigenetic inhibitors of HIV-1

Summary The advent of highly active antiretroviral therapy (HAART) was once perceived to have transformed deadly HIV/AIDS into a treatable, chronic infectious disease. However, mounting evidence now suggests that the prevalence of multi-drug resistant HIV (MDR-HIV) infection is steadily rising among newly infected individuals in the HAART-experienced countries, raising a concern for a future outbreak of MDR-HIV/AIDS. Our global fight against AIDS must include sustained effort to search and discover a new therapeutic modality for HIV infection. Of plausible viral targets explored to date, HIV gene-targeting approach has not yet seen a considerable success in vivo. The pursuit of anti-HIV gene intervention should include the identification of critical gene targets as well as the optimization of biomolecules that can effectively interact with the intended targets. Using unmodified peptide nucleic acids (PNA) as a biomolecular tool, we discovered a potentially critical HIV gene segment within gag-pol encoding gene. Antisense PNA targeting this specific region effectively disrupted a translation of HIV gag-pol mRNA, abolishing the virion production from chronically HIV-infected cells. This exemplifies the possibility that epigenic HIV inhibitors may be developed in the coming years, if emerging novel technologies permit sufficient and stable in vivo delivery of PNA or other similarly effective biomolecules.     

Relevance of studying T cell responses in SIV-infected rhesus macaques

HIV infection, once established, is never cleared. Rare individuals do, however, control viral replication to low levels. These successful immune responses are primarily linked to certain class I MHC alleles (MHC-I). Because of this association, many AIDS vaccines in development are designed to generate virus-specific CD8+ T cells. The Merck STEP phase 2b efficacy trial of one such vaccine was recently halted, and declared a failure. Thus, basic questions regarding what constitutes an effective T cell response and how such responses could be elicited by vaccination remain open. The best animal model available to explore such issues is simian immunodeficiency virus infection of rhesus macaques, which serves as the primary proving ground for AIDS vaccines.     

Therapeutic potential of RNA interference against cellular targets of HIV infection

RNA interference is not only very promising in identifying new targets for drug development, siRNA/shRNA themselves may be directly used as therapeutic agents. In inhibiting viral infections by RNA interference, both viral targets and cellular proteins have been evaluated. Most of the early studies in this field had chosen viral targets for RNA interference. However, recent efforts are mainly focusing on cellular proteins for RNA silencing due to the realization that a variety of viral responses substantially minimize siRNA effects. With the application of siRNA approaching, many new cellular targets relevant to HIV infection have been identified. The value of siRNA/shRNA in the treatment of AIDS is largely dependent on better understanding of the biology of HIV replication. Efforts in the identification of cellular processes with the employment of siRNA/shRNA have shed some new lights on our understanding of how HIV infection occurs. Furthermore, the relative specific effects and simplicity of design makes siRNA/shRNA themselves to be favorable drug leads. J. Zhang and Y. O. Wu contributed equally to this article.     

New ways of preventing HIV infection: thinking simply, simply thinking

HIV infection is the greatest health crisis in human history. It continues to spread unchecked among the poor in the developing world because we have failed to design simple preventative methods that are available and affordable to those living on under Dollars 2 a day. Five new methods are discussed. (i) A natural microbicide. Intravaginal lime or lemon juice has been used for centuries as a traditional contraceptive. The juice can also kill HIV in the laboratory, but clinical trials are needed to see if vaginal application is acceptable, safe and effective. (ii) Intravaginal oestrogen. Monkeys can be protected from Simian immunodeficiency virus (SIV) infection by keratinizing the vagina with topical oestrogen. If women take the oral contraceptive pill vaginally it retains its contraceptive efficacy, and the oestrogen it contains should thicken the vagina and protect against HIV infection. Clinical trials are needed. (iii) Male circumcision. Removal of the inner foreskin removes the main site of HIV entry into the penis, resulting in a sevenfold reduction in susceptibility to infection. The practice needs to be promoted. (iv) Post-coital penile hygiene. Wiping the penis immediately after intercourse with lime or lemon juice or vinegar should kill the virus before it has had a chance to infect. A clinical trial of efficacy is needed. (v) PhotoVoice. Asking schoolchildren in developing countries to photograph their impressions of HIV/AIDS is a powerful way of getting them to discuss the subject openly, and develop their own preventative strategies.