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issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 1 053FIGHTING WORDS inside 333 A new condo development in Vancouver’s Downtown Eastside raises the question of priorities. 063TRAVEL RESTRICTIONS An update on countries that ban the entry of people living with HIV/AIDS. 083DISCRIMINATION A humiliating airport incident becomes an opportunity to raise awareness about HIV. 123MICROBICIDES There’s some hope on the horizon for newer options. 143HIV/AIDS LEADERSHIP An interview with Dr. Julio Montaner, the head of the BC Centre for Excellence for HIV/AIDS. 163HIV CARE REGISTRY BCPWA is developing a registry of physicians with expertise in HIV. 09q AIDS CONFERENCE features q An overview of the 2008 International AIDS Conference, which took place from August 3rd to 8th in Mexico City. 20q TREATMENT AS PREVENTION Swiss experts announced that PWAs with undetectable viral loads were “sexually uninfectious.” Other worldwide authorities called the statement premature. Who’s right? 173AGING AND HIV The population of people with HIV is getting older, which raises a slew of new and unexplored concerns. 233LET’S GET CLINICAL News and enrolling trial updates from the Canadian HIV Trials Network. 243ANTIRETROVIRALS A report on the BC Centre for Excellence’s June antiretroviral update. treatment information 333 263NUTRITION How to keep your food free of bacteria and protect yourself from food-borne illness. 283SIDE EFFECTS A new study reports some immune-related side effects from the facial filler Bio-Alcamid. 303COMPLEMENTARY THERAPIES Turmeric, ginger, and garlic don’t just add flavour, they have healing qualities. 323MENTAL HEALTH How HIV and post-traumatic stress disorder can impact one another. 343STRAIGHT FROM THE SOURCE The first Canadian division of AIDS has been created at the University of British Columbia. 363SIMPLY POSITIVE Our easy-to-read pages on HIV treatment and care. living 5 is published by the British Columbia Persons With AIDS Society. This publication may report on experimental and alternative therapies, but the Society does not recommend any particular therapy. Opinions expressed are those of the individual authors and not necessarily those of the Society. SeptemberqOctober 2008 living5 1 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 2 think 5 opinion &editorial The results of our AGM The British Columbia Persons With AIDS Society seeks to empower persons living with HIV disease and AIDS through mutual support and collective action. The Society has over 4400 HIV+ members. living5 editorial board Wayne Campbell – chair, Michael Connidis, Philip Dawson, Sam Friedman, Rob Gair, Derek Thaczuk, Glyn Townson by Glyn Townson Managing editor Jeff Rotin he membership of BCPWA met for our Annual General Meeting on Saturday, August 23rd, to elect five members to the BCPWA Board of Directors. The newly-elected board members are: 3 Ken Buchanan (vice chair, serving until 2010) 3 Philip Dawson (treasurer, serving until 2010) 3 Ryan Kyle (serving until 2010) 3 Keith Morris (secretary, serving until 2010) 3 Malsah (serving until 2010) 3 Lorne Berkowitz (serving until 2009) The following board members are continuing the second year of a two-year term, and will serve until 2009: 3 John Bishop 3 Damien Callicott 3 Sandy Lambert 3 Richard Theriault 3 Glyn Townson (chair) BCPWA thanks all these members for their support and wishes them good luck during their term on the Board. Unfortunately, the special resolution proposed at the AGM failed by a small margin. The voting members present felt that the resolution to create a mail-in balloting system that would give members outside the Lower Mainland a chance to vote on BCPWA’s business was not adequately developed, and as such they voted against it. This initiative is not dead; the Membership Engagement Committee will be tasked to review the comments brought up at this year’s T Design / production Britt Permien Copyediting Alexandra Wilson Contributing writers Jennifer Chung, Sarah Fielden, Dr. Marianne Harris, R. Paul Kerston, Alix Mathias, Shemina Patni, Ron Rosenes, Neil Self, Shaleena Theophilus, Jennifer Tsui, Tonya Wood Photography Britt Permien Cover photograph International AIDS Society / Mondaphoto Director of communications & education Adam Reibin Director of treatment information & advocacy Adriaan de Vries Treatment information coordinator Zoran Stjepanovic Director of positive prevention Elgin Lim Subscriptions / distribution Edward Klyne, Ryan Kyle, Joe LeBlanc Funding for living 5 is provided by the BC Gaming Policy & Enforcement Branch and by subscription and donations. living5 magazine 1107 Seymour St., 2nd Floor Vancouver BC V6B 5S8 TEL 604.893.2206 FAX 604.893.2251 EMAIL [email protected] BCPWA ONLINE www.bcpwa.org © 2008 living5 Permission to reproduce: All living5 articles are copyrighted. Non-commercial reproduction is welcomed. For permission to reprint articles, either in part or in whole, please email [email protected] 2 living5 SeptemberqOctober 2008 AGM and retool the resolution for our members’ consideration at next year’s AGM, so that all BCPWA members can have a voice. BCPWA encourages its members to share their voices in the upcoming federal election on October 14th. New regulations require that you must prove your identity and address in order to vote. Ensure that you’re on the voter’s list. If you have any questions, or if you don’t receive a voters card in the mail or your address has changed since the last election, call Elections Canada at 1.800.463.6868. We must correct our country’s continued failure to meet Lester B Pearson’s 1970 poverty reduction strategy to commit 0.7 percent of Canada’s gross domestic product to foreign aid. Ask your local candidates to promise to address this situation in the government’s first budget. Closer to home, ask your candidates to commit to maintaining and strengthening the long-term funding of the AIDS Community Action Program (ACAP) funding to ensure that community-based AIDS organizations can continue to address the issues facing PWAs across our country. Make your vote count. 5 Glyn Townson is the chair of BCPWA. issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM A BCPWA success story BCPWA’s treatment information work is reaching far and wide. In mid-June, Miriam Maxcy, an individual advocate at BCPWA, was walking the streets of McLeod Ganj, a small mountainous town in northern India and home to the Dalai Lama, when she noticed BCPWA’s own easy-to-read fact sheets. The fact sheets were posted in the window of Kunphen, a centre for substance dependence, HIV/AIDS, and human resources development that works with HIV-positive Tibetan refugees. Maxcy spoke with the executive director and was informed that the fact sheets were incredibly helpful tools because the pictures told the story well enough for everyone to get the message— even if they didn’t speak or read English. And that’s precisely their purpose. The “Simply Positive” series of easyto-read fact sheets on HIV treatment and care were developed by BCPWA’s Treatment Information Program, in an effort to ensure that HIV-related information is accessible to everyone, regardless of reading ability. Kaletra pediatric tablet in Canada Abbott Canada recently introduced Kaletra (lopinavir/ritonavir) tablets for pediatric patients. The new dosage contains 100 mg of lopinavir and 25 mg of ritonavir per tablet. These tablets are for children weighing over 15 kg who are able to reliably swallow intact tablets. It offers similar advantages as the original strength tablets, including no dietary restrictions (it can be taken with or without food), no refrigeration required. Page 3 Life expectancy with HIV increases dramatically ico City was told that 345 patients in 21 centres in the US and Europe will take part in the largest-ever trial of its kind. The vaccine has been developed by Bionor Immuno, a biotechnology company based in Norway. Results from the trial are due by the end of 2009. A break from standard HIV therapy would potentially alleviate the adverse side effects associated with the drugs, which can include problems with the heart and liver, diarrhea, nausea, and fat loss. It may also help delay the emergence of drug-resistant viruses, as well as providing substantial savings for healthcare services. Source: BBC News A 20-year-old HIV-positive person starting antiretroviral (ARV) therapy today can expect to live, on average, to the age of 69, according to new calculations published in The Lancet. The study authors say this is a life expectancy increase of 37 percent over projections for 20-year-olds starting ARVs during the early years of combination treatment. To determine life expectancy among HIV-positive patients, an international roster of researchers joined forces and reviewed the medical records of more than 43,000 people living with the virus in the US, Canada, and several European countries. The researchers predicted that a 20year-old person starting ARV treatment between 1996 and 1999, the early years of combination ARV therapy, could be expected to live an additional 36 years, to the age of 56. This increased significantly, however, as time passed. A 20year-old who started treatment between 2003 and 2005 was expected to live an additional 49 years, to the age of 69. HIV-positive people who didn’t start ARV treatment until their CD4s dropped to 100 were expected to live 10 fewer years than people who started therapy when their CD4s were above 200. Source: aidsmeds.com Abbott to submit heat-stable Norvir tablet for registration Abbott has announced it will submit registration applications for a novel tablet formulation of its protease inhibitor Norvir (ritonavir) and request priority review by US and European Union authorities before the end of the year. This new, heat-stable formulation will not require refrigeration, which will make it more convenient, particularly in developing countries where the majority of people with HIV live. School gets $100 million for microbicide research The East Virginia Medical School’s Contraceptive Research and Development (CONRAD) program in Arlington was awarded USD $100 million, the largest grant in the school’s history, by the US Agency for International Development to create a product that prevents the transmission of the virus that causes AIDS HIV vaccine could allow “drug breaks” Scientists are testing a vaccine designed to give people living with HIV a prolonged break from their regular medication without side effects. The 2008 International AIDS Conference in Mex- continued on next page SeptemberqOctober 2008 living5 3 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM The grant will help CONRAD further its two-decade study of microbicide creams, topical gels, and oral pills that would block not only HIV but also other sexually transmitted infections. The CONRAD researchers are also trying to develop preventative products that work over long periods of time as opposed to gels that are applied before sex. Source: poz.com Belief in conspiracy theories means less HIV testing in South Africa South Africans who believe in a conspiracy theory that HIV was introduced by white people as a way of controlling the black population are significantly less likely to have had an HIV test, according to a study published in the September 1st edition of the Journal of Acquired Immune Deficiency Syndromes. Investigators designed a study involving 503 men and 438 women who were recruited from sexual health clinics in three townships. They completed a questionnaire Page 4 about their HIV testing history and attitudes and beliefs towards and about HIV. The investigator’s first set of statistical analysis showed that individuals who had not tested for HIV had lower levels of knowledge about HIV and also had more stigmatizing views about the virus. The only belief about HIV that was associated with lower levels of testing was the belief in a conspiracy theory that HIV was created by white people to control the black population. Source: aidsmap.org Suicidal thoughts common in people with HIV Nearly a third of people with HIV from five London clinics reported having had recent thoughts of suicide, according to a study published in the August 20 issue of AIDS. To determine how frequently their HIV-positive patients experience suicidal thoughts and feelings (ideation), Lorraine Sherr, PhD, of the Royal Free and College Medical School in London, and her colleagues enrolled 778 HIV-positive patients from five London health clinics. Roughly half the patients were foreignborn, 67 percent identified as white, and 65 percent were gay men. Sherr and her colleagues asked the study volunteers to complete an extensive survey about their health and psychological wellbeing. Thirty-one percent reported suicidal ideation in the past seven days. Of those, about 5 percent said the suicidal thoughts were constant, and 11 percent said they were frequent. Heterosexual men were almost 50 percent more likely to report suicidal ideation than heterosexual women or gay men. Source: poz.com 2007 HIV/AIDS stats for BC The BC Centre for Disease Control has released its annual AIDS and HIV epidemiological report for the province, this one for the 2007 calendar year. To view the report, visit www.bccdc.org/downloads/ pdf/std/reports/HIV-AIDS%20Update %20Report_2007.pdf. 5 photo by Mike Verburgt At the August AGM, BCPWA members elected a new Board of Directors (see page 2). The 2008/2009 BCPWA board from left to right: Ryan Kyle, Malsah, Damian Callicott, Philip Dawson, Richard Theriault, Glyn Townson, Keith Morris, Ken Buchanan, John Bishop, Loren Berkovitz, Sandy Lambert. 4 living5 SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 5 FIGHTING WORDS Bucks versus basics New condo development in Vancouver raises the question of priorities and discrimination by R. Paul Kerston IV doesn’t discriminate. It affects men, women, and children of all ages, races, and socio-economic status. That said, lower socio-economic status is linked to a higher risk of becoming HIV-positive. For those living with HIV, the lack of stable and affordable housing impacts many areas of daily life, from taking medications to co-infection, and beyond. People need housing before they can face other basic needs. HIV-positive people taking antiretrovirals need to be adherent. However, adherence is difficult when basic things such as storing medication and access become problematic—as they do for those without adequate housing. People searching for shelter and food may unwittingly sacrifice medical treatment in their search for these basic needs. That’s why BCPWA monitors and advocates for adequate social housing. Nowhere is the need for housing more obvious than in Vancouver’s Downtown Eastside (DTES). And that’s why a new condo development in the DTES has advocates up in arms. In late June, the City of Vancouver’s Development Permit Board approved Concord Pacific’s proposed condo plan at 58 West Hastings Street. Despite acknowledging that 200 letters were received—all negative —and despite the fact that all 40 people attending the Board hearing (including a street pastor, nearby condo owners, and residents) spoke against the development, the Board seemed to feel that putting this out-of-context monstrosity for high rollers within the midst of the DTES was more important than housing local residents at risk of peril and even death. Maybe city planners thought the municipal-provincial development of 12 social and supportive housing buildings, plus the 2007-2008 provincial purchase of 16 hotel single room occupancy (SRO) units—a lousy alternative to proper housing, but a start— was enough for the community. Interestingly, the government’s figures indicate that of the 925 hotel units they purchased, only 626 (not quite two-thirds) are within the DTES. Yet we know that there are roughly one to two new infections per year for every 100 people in the DTES, and that about 30 percent of that population is currently infected. Statistics also indicate that between 1995 and 2001, one-third of the people who died from HIV-related causes never accessed antiretroviral treatments. H SeptemberqOctober 2008 Agencies are moving into the DTES to expand access to services, but without governments addressing basic human needs, starting with stable and affordable housing, agency work could be largely for naught. People look for housing before medication. They require food and shelter before pills. It would appear that the almighty dollar’s power to build condominiums speaks louder than the need of people seeking basic shelter. Maslow’s hierarchy of needs states that basic physiological needs—including food, water, and sleep/housing—must be met before issues of safety, love, belonging, and esteem can be addressed. In the DTES, these basic physiological needs are often met in the most temporary and haphazard ways, which means that the latter needs are often met through sexual or self-medicating behaviours that increase the risk of HIV infection. Moreover, people may seek to secure housing via sex work, also increasing the risk of HIV infection. If that’s the case, and with Vancouver’s 2008 homeless count of at least 1,547 persons, why isn’t there a greater commitment to provide housing in the DTES for those most at risk? It would appear that the almighty dollar’s power to build condominiums speaks louder than the need of people seeking basic shelter. Gosh, that smacks of discrimination. BCPWA, largely through its Community Representation and Engagement Committee, is fighting discrimination like this. HIV doesn’t discriminate. Why does government? 5 R. Paul Kerston is BCPWA’s treatment outreach coordinator and community representation and engagement (CRE) coordinator. living5 5 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 6 Refused entry An update on HIV/AIDS-related travel restrictions by Ron Rosenes eople living with HIV who want to travel for pleasure, emigrate, or are forced to flee their home country as refugees have a champion in the International AIDS Society (IAS), which is taking a leadership role in advocating for change among the 9 countries that ban HIV-positive people from crossing their borders. These countries include the US, China, and Saudi Arabia (see sidebar). The IAS serves as the secretariat for the International Task Team on HIV-related Travel Restrictions, convened by the Joint United Nations Programme on HIV/AIDS (UNAIDS). The Task Team is comprised of representatives from governments, United Nations agencies, and civil society organizations including GNP+, ICW, the Canadian HIV Legal Network, UN, WHO, and Labour and Human Rights Watch. The Task Team will provide recommendations to UNAIDS and the Global Fund to Fight AIDS, TB, and Malaria to remove HIV-related travel restrictions at country and regional levels, in both the short term and long term. Several events at last month’s International AIDS Conference in Mexico City added to advocacy efforts and issued a call to all countries that restrict the short-term entry of PWAs and/or require prospective visitors to declare their HIV status to lift these discriminatory policies. The IAS is also urging countries to review their policies relating to HIV and restrictions on immigration, refugees, people wishing to adopt HIVpositive children, and student visas in light of sound public health evidence and human rights principles. P Visaprocesschangesatthe2006AIDSConference A great step forward occurred in 2006 when changes were made to the visa process for HIV-positive people coming to Canada to attend the last International AIDS Conference in Toronto. The Canadian visa form was successfully changed from asking about “any chronic condition, including HIV” to inquiring specifically 6 living5 about active TB, a highly contagious airborne pathogen that was the main concern of health authorities (along with a second question about potential burden to health and social services). This important precedent is now being used by IAS-led advocates to achieve change in the laws of other countries. Many of the countries that have travel restrictions in place did so at a time of high crisis and limited understanding of the communicability of HIV at the time. Twenty-five years later, most would agree travel ban laws don’t reduce HIV transmission. Such laws ultimately deny our collective responsibility for HIV and create a false sense of security among citizens that hinders sound prevention efforts, including raising awareness of their own vulnerability. IAS argues that HIV-specific entry, residence, and stay restrictions imposed by the US government are counterproductive to sound public health policy, because they encourage people to lie about their status. This could further drive the epidemic underground. Because of this, the International AIDS Conference can’t be held in the US. The risk of going off meds to enter a country Studies have shown that when these restrictions are imposed, people living with HIV will interrupt their treatment regimens while travelling to countries that monitor HIV status; as a result, they risk developing a resistant virus due to non-adherence. Scientific evidence following the introduction of highly active antiretroviral therapy (HAART) shows a significant reduction of viral load and infectivity of HIV-positive people on treatment. The scale-up of access to universal treatment coupled with the falling cost in low- and middle-income countries dispels the myth that mobile PWAs would drive up the cost of health and social systems abroad. As Violetta Ross, a PWA from Bolivia said at the United Nations General Assembly Special Session (UNGASS) earlier SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 7 this year in New York: “HIV-related travel restrictions create and perpetuate the myth that the risk of AIDS is outside our borders, violate fundamental human dignity and human rights, fuel stigma and discrimination against those of us living with HIV; deny the greater involvement of people living with HIV in the response to the epidemic, and deny an honest discussion on the linkages of mobility, migration and HIV.…HIV-related travel restrictions are discriminatory….even migratory birds have laws and treaties that protect them while moving across borders, but not human beings living with HIV.” The recent meeting of the Global Fund held in China points to some progress being made there. China’s current visa application form, introduced in September 2007, requires disclosure of HIV status as a condition for entrance into the country. For the Global Fund meeting in November 2007, the Chinese Ministry of Health implemented a special waiver to ensure no delegate would be required to disclose their HIV status on visa forms or upon entry to China. Following a series of meetings, on November 8, 2007, the Chinese Ministry of Health announced its commitment to changing its immigration laws, scrapping travel restrictions that limit entry of people living with HIV. The proposed changes to Chinese law, which will no longer require declaration of HIV status, should be submitted for decision in the first half of 2009. The Global Fund has now adopted the IAS policy regarding the countries where it will hold future meetings. Trying to change the laws in the US Progress in the US has been harder to come by. Putting aside the history of travel restrictions, which, sadly, were signed from policy into law in 1993 by President Clinton, some change is afoot. It will however require Congressional legislation and signature of the President, either in the form of stand-alone legislation or as an amendment to a larger bill. Under the current law, eligibility for any type of waiver requires individuals to disclose their HIV status. When a “streamlined” process was announced in November 2007, it only made the existing law more stringent, and still required PWAs to declare their status before entering the U.S. The IAS has urged the US government to table the rules around this so-called streamlined process and to hold a public review of the existing legislation. The Center for Strategic and International Studies, in its March 2007 report, Moving Beyond the U.S. Government Policy of Inadmissibility of HIV-Infected Non-citizens, examined challenges and options for current US law, and proposed that US policy should be consistent with current scientific knowledge, public health best practice, and aligned with humanitarian principles. US Congressional Representative Barbara Lee introduced the “HIV Non-discrimination in Travel and Immigration Act” in August 2007. This bill seeks to amend the 1993 legislation by striking the provision that renders PWAs inadmissible to the SeptemberqOctober 2008 Countries that ban PWAs Countries that ban HIV-positive persons from entrance, residence, and stay are Brunei, China, Oman, Qatar, South Korea, Sudan, United Arab Emirates, the US, and Yemen. Some 58 additional countries have some other form of residence or immigration barriers based on HIV status. For a complete listing of these countries, go to www.hivtravel.info. US. It would return authority to the Secretary of Health and Human Services to decide the status of HIV as a communicable disease of public health significance. It would mandate a public health review of all policies regarding the continued listing of HIV as grounds for inadmissibility into the US. A report from the process would be made available for public comment, and findings submitted to Congress on whether to maintain the ban by regulation or remove it based on public health analysis. While Representative Lee’s proposal still falls far short of overturning the discriminatory policy, it may pave the way to have the law repealed. Saudi Arabia’s new HIV Bill of Rights On to Saudi Arabia, which protects Saudi citizens, but visitors and migrants beware! Under a newly proposed “HIV Bill of Rights,” the Saudi government proposes screening visa applications if they are from countries “proven to have an AIDS outbreak” to “prove the absence of AIDS virus in such persons.” Additionally, the Saudi Ministry of Health would “examine those arriving in country for the purposes of residence to make sure s/he is not infected with the AIDS virus.” I attended the meeting in Mexico to learn more about future advocacy plans on HIV-related travel restrictions and look forward to sharing them with you. My flight to Mexico was direct, non-stop from Toronto—in case you were wondering. 5 Ron Rosenes is co-chair of the Canadian Action Treatment Council, co-chair of the Community Network Advisory Committee of the Ontario HIV Treatment Network, and a board member of AIDS Action Now. News update On Wednesday July 16, 2008, the US Senate passed the PEPFAR (President’s Emergency Plan for AIDS Relief) bill and the section on the repeal of HIV travel and immigration restrictions passed along with it. This is one step in a longer process that will hopefully lead to change. living5 7 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 8 Flight or fight —or educate A humiliating airport incident turns into an opportunity to raise awareness about HIV by Jennifer Tsui been over 25 years since the first case of HIV/AIDS was reported, yet ignorance about it—right in our own province—is still shockingly commonplace, as Positive Living North (PLN) discovered last spring. The organization’s reaction, however, was anything but commonplace. And the final outcome was heartening. On March 28, nine members of PLN, an AIDS support group in Prince George, were boarding a WestJet flight to attend BCPWA’s Positive Gathering conference in Vancouver when they were stopped by a security guard. The guard, a member of a private security company, raised concerns about the members’ “disease” and the possible danger they posed to the flight crew and other guests. The flight was delayed until one of the PLN members spoke to the pilot who subsequently dismissed the guard’s concerns and continued with regular flight procedures. Not only were the members of the group traumatized by such treatment, the incident shocked the AIDS community and sparked international media attention. “My first reaction when I heard what had happened was disbelief—I couldn’t believe that in 2008, we were still experiencing this,” says Catherine Baylis, executive director of PLN. Given the outrageous nature of the incident, PLN could have justifiably reacted in numerous ways, from demanding compensation to taking legal action; but the organization was adamant that its response be positive and constructive. “We said to ourselves: this happened, this is inappropriate, this is unacceptable—what’s the best way to approach it?” says Baylis. “PLN is so grounded in its beliefs about education that we knew that’s what we wanted to do. We knew anger wouldn’t move things forward.” That mentality led to a full day of sensitivity training with all the security managers and supervisors from virtually every airport in BC. The training, which was essentially HIV 101, covered basic information like how—and how not—HIV is transmitted. Participants were provided with resources and materials they could take away to educate staff in their respective airports. In addition, members of the delayed group were present to share their experiences. The response they received from the security personnel was overwhelming. The personnel are now determined to move forward with their learning and prevent similar incidents from happening in the future. It’s 8 living5 “When something like this happens, we can choose to build bridges instead of building walls. How can we shift attitudes and understanding if we choose the latter?” – Catherine Baylis, executive director of Positive Living North “It was totally amazing, I couldn’t ask for anything more from an education session,” says Baylis, adding it was so compelling that people on both sides were moved to tears. “People left the training with more information than when they arrived, and with an absolute desire to do something with it.” While other groups may have taken more aggressive action after such an embarrassing incident, PLN chose instead to raise awareness. And hopefully those enlightened security personnel will share their knowledge with family and friends. “I have a profound belief that education can change the world, and I got to see that change in action,” says Baylis. “When something like this happens, we can choose to build bridges instead of building walls. How can we shift attitudes and understanding if we choose the latter? Building bridges and education is what our work is all about.”5 Jennifer Tsui is a Vancouver-based freelance writer. SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 9 Cover Story Universal action now A report on the XVII International AIDS Conference, August 3 – 8, Mexico City by Glyn Townson © International AIDS Society/Mondaphoto XVII International AIDS conference, the first to be held in Latin America, took place at the Centro Banamex Convention Centre in Mexico City with over 25,000 in attendance. Overall, the city was welcoming and friendly, if somewhat congested. The opening ceremonies took place on Sunday at the Auditorio Nacional, a distance from the conference centre, with the The SeptemberqOctober 2008 Mexican President, Felipe Calderón Hinojosa, and other foreign dignitaries in attendance: Festus Mogae, former President of Botswana; Maria Teresa Fernández de la Vega, First Vice-President of Spain; Denzil Douglas, Prime Minister of St. Kitts and Nevis. President Calderón gave an official welcome—a far cry from AIDS 2006 in Toronto, where we couldn’t even get our prime minister to make an appearance. living5 9 continued on next page issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 10 Cover Story The opening ceremonies included colourful entertainment and music, and welcoming remarks from the conference co-chairs, Dr Pedro Cahn and Dr Luis Soto-Ramirez. Dr Peter Piot, the executive director of the Joint United Nations Programme on HIV/AIDS, gave the keynote address, and Mony Pen, a Cambodian living with HIV, also gave a moving speech. It was obvious that the Mexican government had made special efforts over the past several years to make AIDS 2008 in Mexico City a success. By focusing on HIV and making it a priority issue, it was possible to build a political case to give operational meaning to universal health coverage. While other countries, even Canada, let health services slide, Mexico has committed an additional one percent of its GDP to medical services over the next seven years. There are still capacity issues, and to date 22 million people have access to coverage—approximately 22 percent of the population— with a goal to reach full access by 2015. The government has worked on changing laws allowing for expanded healthcare—rights entrenched in the country’s constitution—and legislation banning homophobia, including the launch of a country-wide anti-homophobia campaign. They have also identified the problem of violence against women and girls. Most evident of the government’s commitment is that Jorge Saavedra López, the head of Centro Nacional para la Prevención y el Control del VIH/SIDA, Mexico’s national HIV/AIDS program, is himself HIV-positive, openly gay, and legally married to his partner. Prevention strategies must be realistic The theme of the conference was “universal access to treatment, medications, and prevention now.” The barriers are ignorance, human rights violations, and poverty. At long last, there was a full recognition of the importance of a human rights based approach to HIV/AIDS, especially among vulnerable populations. Prevention must go hand-in-hand with treatment. The conference from start to finish was full of emotion and passion. The basic message, repeated over and over, was that current knowledge and research have proven that the treatments work, even in resource-poor conditions. The current global prevention strategies of abstinence and being faithful are clearly not practical. Future efforts in prevention must be researchbased and specific to the populations being addressed. Although many countries still don’t acknowledge men having sex with men (MSM) as a local problem, recent studies have shown that in all cases MSM are over-represented in the numbers of new infections. The harsh reality is that for every person starting antiretroviral therapy, three more become infected, making prevention efforts tantamount to the fight against HIV. The message was loud and clear that we can’t treat our way out of this pandemic. Approximately three million people are now on antiretroviral therapy, with about 20 million currently requiring therapy. 10 living5 More recognition of—and funding for— high-risk groups Proven strategies for harm reduction and prevention methods where highlighted throughout the conference. In all cases, the successful programs had several basic principles in common: greater involvement of persons living with HIV; addressing local problems and situations with local solutions; and education in the context of the lived experience of those in risk of contracting or spreading HIV. “The AIDS dragon does not ravage the world alone. Its partners are the unconscionable inequalities of health care, poverty, and education, which are things we can do something about…We must work tirelessly…until the day for all the world’s children comes when the dragon is slain and all the children’s dreams can dance.” – Bill Clinton While there has been little funding targeted directly at highrisk groups such as sex trade workers, intravenous drug users, and MSM, novel approaches around the world have been making some progress. But clearly more resources must be made available—without moral and faith-based restrictions—if we’re going to get a real grip on prevention and make a tangible dent in the numbers of new infections around the world. An Argentinean sex trade worker, who was part of the Thursday plenary, talked about her struggle getting recognition from UNAIDS, which deemed the profession second class and recommended retraining. She passionately cried out, “I don’t want to learn how to sew! I don’t want to learn how to cook! I know what I’m doing!” Her presentation also focused on Canada’s spending priorities, with enforcement getting the lion’s share at over 70 percent, while harm reduction was a mere 2 percent. The point of her plenary was to show that sex trade workers are part of the solution, not part of the problem. By stigmatizing and criminalizing their work, they’re put at great risk for violence and have no protection or recourse when they’re victimized. SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 11 Cover Story Demonstrations about homelessness, drug costs, and women’s rights Activists were present throughout the conference, including the opening ceremonies, though they had been warned that they could face $1,000 fines, removal from the event, and deportation. They still managed to unfurl a banner at the opening ceremonies to protest the lack of housing and services for the homeless living with HIV. There were daily protests on homelessness; some interrupting plenary and key speakers, including Bill Clinton. There was a strategy area in the Global Village for activists to meet and plan demonstrations throughout the conference. An on-site demonstration of coffins, skeletal masks, and black capes brought attention to the stalled negotiations between the government and Abbott Laboratories regarding second-line therapies for those whom the current drug regimens are no longer working. (Interesting how there was no official Abbott presence at AIDS 2008—a reminder of the booth takeover at the International AIDS conference in Toronto in 2006.) The current standoff remains that Abbott has refused to cut the Mexican government a deal on Kaletra—it offered a miserly five percent discount, amounting to a cost of $450 per month per patient, while people in other Latin American areas pay as little as $45 a month for the same treatment, according to one of the activists. Many of the activists in the demonstration were themselves ill, and are waiting desperately to get access to the second-line therapies. Some things never seem to change. There was also a major anti-homophobia march in the historical district of Mexico City on the Saturday preceding the conference, and a well-attended women’s march and rally from the Juarez complex to the Zócolo the next day, which was addressed by singer Annie Lennox. The success of combining HIV, TB, and malaria services All the daily plenary sessions were exceptional. President Bill Clinton was one of the keynote speakers and addressed the problems of delivering quality services to those in resourcepoor countries. The burden of HIV is born mostly by women. He highlighted the successes of combining tuberculosis and malaria services with existing HIV clinics, providing a one-stop shop for patients to get the care they need without having to travel to different places and different providers. Today, 1.4 million people are receiving antiretroviral therapy through the Clinton Foundation. (There are currently about three million people around the world on antiretroviral therapy). The Global Village was the largest one to date at an international AIDS conference. It was a hive of activity the entire week, with brilliant entertainment from around the world— including some of our own local groups, YouthCO and Healing Our Spirit, who put on a popular forum theatre performance. A colourful international marketplace with handSeptemberqOctober 2008 crafted wares, large centre stage, various meeting areas for networking, and art installations added to the ambience. Youth involvement was at its highest to date, a trend which will hopefully continue to future conferences. Full human rights for the most vulnerable populations At the closing session, Dr. Julio Montaner assumed his role as the new president of the International AIDS Society (IAS), taking over from Dr Pedro Cahn. He welcomed the presidentelect, Elly Katabira, who will be the first African president of the IAS. She is an associate professor at the Faculty of Medicine at Makerere University in Uganda. Dr. Montaner’s opening speech challenged Prime Minister Stephen Harper and all the G8 countries to step up to the plate and follow the example of the US with its renewed President’s Emergency Plan for AIDS Relief (PEPFAR) funding, which was recently announced by President George W. Bush. Dr. Montaner also congratulated the US for its announcement to lift the travel ban for those living with HIV. Dr. Montaner ended his speech by saying that there can be no end to the pandemic unless we secure full protection of human rights for those most vulnerable to HIV/AIDS. The rights of sex trade workers, injection drug users, MSM, aboriginals, and women and girls must be protected through legal and policy reform in every country around the world. Dr. Montaner noted that we still have a long way to go, and he called on all political and religious leaders to make this a reality. “We know what has to be done,” he said. “We must strive for universal action now! Anything less would be a crime.” On the whole, AIDS 2008 felt as if it had tied the loose strings together and revitalized the community movement to tackle barriers facing those infected and affected by HIV/AIDS. Although, as always, there is a daunting amount of work to be done, we know what directions must be focused on: a combination of therapy, prevention—and universal action now. All eyes will be on Vienna in 2010 for the XVIII International AIDS Conference. The conference will coincide with the deadline that world leaders set for the goal of providing universal access to HIV prevention, treatment, care, and support. 5 Glyn Townson is the chair of BCPWA. Watch the sessions The opening ceremony and all plenary sessions can be viewed online at www.aids2008.org living5 11 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 12 Microbicides: the next generation There is some hope on the horizon for newer options by Shaleena Theophilus ver the past few years, the field of microbicide research has advanced considerably, with a few setbacks. There is some hope on the horizon with what’s being called second-generation microbicides. A microbicide is a substance that can reduce the transmission of HIV and other sexually transmitted infections when applied in the vagina or rectum. What makes a microbicide unique is that it’s user-initiated. This provides options for people who are unable or unwilling, for a variety of reasons, to ask their partners to use a condom. Currently we don’t have any proven microbicides on the market, however products are under development. If and when they are available, they’ll probably be in the form of gels, foams, creams, or suppositories. These first generation microbicides will likely be contraceptive, since it’s much harder to develop one that neutralizes viruses and bacteria without affecting sperm. This would benefit women who would like a product that both protects them from diseases and prevents pregnancy. Scientists are also working on products that will be noncontraceptive. This is a suitable alternative for women who choose not to use contraceptives for religious or cultural reasons, as well as for women who want to conceive a child while still protecting themselves from infection. This second generation of microbicides will be able to be applied several hours before intercourse, and will come in vaginal rings or sponges, which slowly release the product over time. Studies combining microbicides, diaphragms, and cervical caps are also underway. O Different classifications of microbicides Microbicide products under development fall into five classifications. The first classification is blocking agents, which provide a barrier to prevent infection. The second type, called 12 living5 surfactants, would kill or disable the virus by breaking down its surface membrane or coat. These would resemble spermicides, which work by breaking up the outer coat of the sperm, thus making the vagina inhospitable to HIV. The third class of microbicides are the vaginal defence enhancers. The vagina normally has a very acidic pH level, but sperm counteract this acidity, making it possible for HIV to survive. By maintaining the vaginal pH at a level that destroys viruses, the vagina would inhibit the survival of HIV, thereby reducing the risk of HIV transmission. Another category of microbicides prevents the virus from entering white blood cells. Two varieties of these entry inhibitors are being researched: attachment inhibitors, which prevent the virus from attaching to white blood cells, and fusion inhibitors, which prevent the virus from entering the cells. The fifth group of microbicides involves reformulating the antiretroviral drugs developed to treat people living with HIV. Researchers are now experimenting to determine if drugs that have been reformulated for use as topical gels or creams could stop localized HIV replication in cells in the vagina, before it enters the bloodstream. The first microbicides will likely be only 40 to 60 percent effective. However, the London School of Hygiene and Tropical Medicine calculated that if a product that’s 60 percent effective is offered to 73 lower income countries, and is used by 20 percent of people reached by healthcare during 50 percent of sex acts when a condom isn’t used, 2.5 million new HIV infections over three years can be averted. When a microbicide is available on the market, some will use it for anal intercourse, since HIV is more easily transmitted to a receptive partner during unprotected anal intercourse than during unprotected vaginal intercourse. Therefore, it’s important to study the safety of vaginal microbicides for rectal use, as well SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 13 as to develop products specifically for anal intercourse. The physical structure of the rectum is much different than the vagina and provides additional challenges to creating an effective product. Phase 1 studies are currently underway in the US. Microbicides that are undergoing trials All microbicides must undergo Phase 1 and Phase 2 safety trials. If the product is found safe in these studies, they then advance to larger scale Phase 3 trials, or what is also referred to as a Phase 2b trial. What makes a microbicide unique is that it’s user-initiated— providing options for people who are unable or unwilling to ask their partners to use a condom. As of July 2008, there were 12 microbicide candidates in clinical trials. Among them: Cellulose sulfate: Also known as Ushercell, this product is a cotton-based compound. The initial tests were promising, and the product went in to Phase 3 studies in South Africa, Benin, Uganda, and India. However, in January 2007, the Data Safety and Monitoring Boards halted the trials. At that time, the interim analysis showed that the product was not effective in preventing HIV infection. Data from some trial sites suggested that the product might have increased a woman’s chance of acquiring HIV. The data is being analyzed to try to uncover the reason for these results. Carraguard: This microbicide candidate is an odourless, clear gel made out of carrageenan. Carrageenan is a common thickener made from seaweed, which has been used in foods for years. Phase 3 studies of this product were conducted from 2004 to 2007 in South Africa. Although the product was both safe to use and acceptable by women, it wasn’t effective in reducing the risk of acquiring HIV. However, this trial was an important landmark: having enrolled over 6,000 women, it was the first large-scale microbicide trial to continue until its completion. indicated that the 2 percent dose didn’t show a significant protective effect over the placebo. However, the 0.5 percent dosage arm of the study will continue and yield results in 2009. BufferGel: BufferGel is a vaginal defense enhancer. It’s an acid buffer that maintains the vaginal acidity, even in the presence of sperm. It also creates a physical barrier that stops or slows the virus from entering the vaginal and cervical walls. Currently, it’s being tested in Phase 2/2b trials, where it’s being compared with the 0.5 percent dosage of PRO 2000. These trials are taking place in South Africa, Malawi, Zimbabwe, Zambia, and the US. Tenofovir gel: Tenofovir is an antiretroviral drug that has traditionally been used to treat people living with HIV. Over the past few years, it’s also been researched as a potential prevention method. Initial studies on the safety of tenofovir gel showed that it’s safe for sexually active HIV-negative women to use daily for an extended period of time. Building on these results, Phase 2b trials in South Africa are being conducted. Future studies of the tenofovir gel are also planned, including the VOICE study, which will examine its effectiveness if used every day, instead of just at the time of intercourse. Given that the product is longer acting, it can be inserted well before intercourse, thereby providing more options for people. Enrollment is expected to begin in 2009, which will review the effects of the tenofovir as a microbicide in pregnant women. The VOICE study will also evaluate pre-exposure prophylaxis, a prevention approach involving the daily use of oral antiretrovirals. Dapivirine—which is being used in vaginal rings as opposed to the gel formulation—and UC-781 are two other antiretroviralbased candidate microbicides currently in Phase 1 studies. Finally, the invisible condom, created at the Université Laval in Québec, is an entry/fusion inhibitor. The key ingredient is sodium laurel sulphate, a compound used in soaps and toothpaste to fight viruses and bacteria. As more candidates are being researched, there is still much hope for microbicides and the potential they hold for helping stem the transmission of HIV. 5 Shaleena Theophilus is a program consultant at the Canadian AIDS Society and coordinates the Microbicides Advocacy Network Group (MAG-Net). Other microbicide candidates in the pipeline There are several microbicide candidates in the product pipeline. The furthest along in clinical research include: PRO 2000, BufferGel, and tenofovir gel. There are also a few planned for additional studies, including the invisible condom. PRO2000: This product is an entry and fusion inhibitor that binds to the virus and prevents it from infecting a healthy cell. It is currently in Phase 3 trials in South Africa, Tanzania, Uganda, and Zambia. Researchers were testing gels, one containing a 0.5 percent dose of the product, another containing a 2 percent dose. However, in February 2008, an interim analysis SeptemberqOctober 2008 For more information For more information, visit the following websites: q Canadian AIDS Society, www.cdnaids.ca q Global Campaign for Microbicides, www.global-campaign.org q Alliance for Microbicide Development, www.microbicide.org q International Rectal Microbicide Advocates, www.rectalmicrobicides.org living5 13 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 14 Leader of the pack Dr. Julio Montaner talks about the leadership role of the BC Centre for Excellence Dr. Julio Montaner is the director of the BC Centre for Excellence in HIV/AIDS. At the end of the International AIDS Conference in Mexico last August, he also became president of the International AIDS Society. Living 5 Magazine: What are your top priorities for the Centre? Julio Montaner: In the last couple of years, we have put a tremendous amount of effort trying to optimize access to antiretroviral therapy in British Columbia. First and foremost, it prevents the progression of the disease, prolongs life, and improves quality of life, and an important secondary role is to decrease infectiousness as a result of treating viral load. I want to emphasize that treatment is not meant in this context as a replacement for traditional preventive strategies such as safer sex or harm reduction. Being on treatment doesn’t mean that one cannot infect, but rather being successfully treated renders you less likely to transmit. So if all the precautions are in place, at the end of the day the equation is a lot more favourable. LP: What do you feel are the key challenges that the Centre currently faces? JM: I’m limiting my discussion to the expansion of HAART so it’s not too broad. The number one thing we must recognize is that when it comes to expanding antiretroviral therapy coverage among those in medical need, it’s no longer the fact that the pills aren’t available or the treatment is complex or toxic. We have overcome those issues to some extent. Today, it has a lot more to do with who are the individuals that are failing to access treatment in a timely fashion, or who don’t know they’re infected. Unfortunately, we still see a significant number of people who receive their first HIV test after they develop an AIDS-related complication. That’s why we’ve made the “seek” part of the “Seek and Treat” proposal an important priority. We want to ensure that case finding is a priority, that we enhance HIV testing. 14 living5 The next challenge pertains to the variety of circumstances that lead people to neglect antiretroviral therapy as a priority. Social, cultural, and lifestyle issues play a very important role, whether it’s a single mother with no babysitting resources who fails to get to a medical visit, or a homeless person, or a person who has no food security, or a person who is challenged with other co-morbidities such as mental illness or addiction. Any one of those represent very big challenges when it comes to the implementation of effective, high coverage for antiretroviral therapy. At the end of the day, a successful campaign to advance HIV diagnosis, appropriate engagement of HIV care, and eventual successful engagement of antiretroviral therapy among those in medical need, will require substantial strengthening of the support that we’re able to provide. That really is beyond the immediate ability or mandate of the Centre. So it’s more of a multi-agency challenge where we have identified the importance of rolling out antiretroviral therapy in a more effective way. This is not something we can hope to do unless there’s a concerted effort on the part of the municipal and provincial government. I’m very impressed by the amount of encouragement and support that we’ve gotten from the Minister of Health and the Premier himself. In reality we can only bring the so-called medical interface to this initiative. The larger social dimension is well beyond our scope. LP: So what you’re saying is it’s for other agencies to pick up on this and move forward with it. JM: Exactly. The reason we have developed this research initiative is because we believe that if we were able to demonstrate that the additional preventive value of antiretroviral therapy is “x”, then SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 15 we can take that to third-party agencies, whether it’s the rest of Canada or the developing world, and help them to devise programs and policies. Rolling out antiretroviral therapy anywhere in the world becomes difficult to sustain unless it’s also contributing to the control of the growth of the epidemic. Once you look at it from that perspective, it gives you a much better opportunity to engage international donors because they now understand that this is not just about saving a life—you can save a life with mosquito nets, you can save a life with clean and safe drinking water—this contributes to curbing of the epidemic. That’s the biggest challenge we face. LP: How certain are you that the “Seek and Treat” strategy will continue to be funded after its initial trial period? JM: We’re not talking about doing a trial per se—we’re not testing antiretroviral therapy. The whole gist of what we’re proposing is that we have been failing to do what we said we intended to do, which is to offer treatment effectively to individuals who need treatment. So from that perspective there is no real research in terms of the treatment aspect of things. The research part of it has to do with once you do what you were supposed to be doing, what would be the impact on the larger societal scale of doing so. Whether we prevent one additional case or 100 doesn’t really matter—I mean, it’s important, but it’s not directly relevant to the decision of whether or not we continue to treat the people we need to treat. Because those people need the treatment regardless. So the research questions around the implementation of the Seek and Treat proposal have to do with where are the appropriate or best or most effective mechanisms to engage people in testing, treatment, and care on a sustained basis. If we were able to show that one strategy is better than another, I think it would be very reasonable to suspect that the knowledge we derive from that will become the standard of care. With regards to the treatment, it’s business as usual. The province of BC has made a commitment all along that it will fund antiretroviral therapy for individuals within the province who meet the criteria for treatment. I have absolutely no doubt that the provincial government intends to fulfill their promise on a long-term basis. I want to strongly emphasize that the “treat” part of this proposal is not experimental, the experiment here is to measure the societal impacts of doing a better job of treating people that we decided need treatment. So in that context, this is a no-brainer! LP: Given that there’s an increased budget for the enhanced Drug Treatment Program, what guarantees are there that the money won’t be taken from money that’s going to community-based responses? JM: First, expanded therapy at this time has no budget. It’s a theoretical concept that we have put forward. We have modelled it mathematically and currently the government is studying our proposal to try to understand what it would take to make it happen. The Centre’s position has been and continues to be SeptemberqOctober 2008 “When it comes to expanding antiretroviral therapy coverage, it has a lot more to do with who are the individuals that are failing to access treatment in a timely fashion, or who don’t know they’re infected.” that for the expanded HAART proposal to be successful, it can only get there by strengthening the current systems that we have in place. That includes everything that is currently successfully in place operating at a proportionally higher level so that it can accommodate the increased complexity and challenges associated with expanding coverage. We have not worked out a budget fully because it would be easy for us to tell you that, if we treat x number of people with x number of dollars, if we were to treat double the number of people, we will need double the number of dollars. And laboratory tests will cost double. The challenge is to try to understand what additional resources are necessary to successfully engage people on appropriate testing practices, appropriate engagement of care, and sustained engagement on HAART over and beyond what is currently available. And to be honest with you, we have no idea because simply we have failed to do it so far I am assured in our discussions with the Ministry representative that they understand that there is an uncertainty regarding what exactly it would take to put these programs in place. All along we have strongly indicated that the successful implementation of this program will require more, rather than less, support at the community level because we will be engaging individuals who are in more vulnerable situations. It’s important that their needs be accommodated. LP: How will your appointment as president of IAS impact your work at the Centre? JM: I’ve been on the governing council of the IAS for nearly a decade. So I’ve been able to do meaningful work at that level without people being affected by my distractions from time to time. So, in the role of president of the IAS, my time will be increasingly taxed as it has been for quite some time, but we have a country of younger colleagues prepared to help out. At the end of the day, my role in the IAS hopefully will not just benefit the IAS and the world, but will also benefit the Centre. It will add an international dimension to what we’re doing, strengthening our leadership role in Canada and internationally. It can act as a facilitator for our national and local government to continue to support some of the novel work we’re doing. 5 living5 15 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 16 Hot docs BCPWA is developing a provincial registry of physicians who have expertise in HIV by Neil Self inding a family doctor in British Columbia is a challenge. Finding a doctor who has experience in HIV care is even more challenging. HIV positive people need access to the healthcare system and they need to establish a strong doctor-patient relationship. That’s why BCPWA is developing the HIV Care Physician Registry, a province-wide registry of physicians who self-identify as experienced in HIV care and are currently accepting new patients. According to the 2006 Census, BC has a population of over 4 million and just under 6,000 general practitioners or family physicians in the province—which works out to about 696 British Columbians for every family physician. To make matters worse, of the 6,000 general practitioners, only 400 are currently accepting new patients. The BC Centre for Excellence in HIV/AIDS (BCCfE) has about 700 physicians—including family physicians and specialists—registered with their programs and services; 60 of them have registered with the BCPWA HIV Care Physician Registry as accepting new patients. While that’s encouraging, bear in mind that, in addition to the current 13,000 HIV positive people in BC, there are, on average, about 400 new HIV infections every year. Geography and context are also important factors in accessing qualified doctors. There’s a more significant lack of HIVexperienced doctors outside Metro Vancouver. Stigma, cultural competence, and discrimination are barriers to accessing a family doctor in many rural communities. Cultural competence means being educated, competent, and comfortable discussing issues related to the sexual culture of gay and bisexual men and men who have sex with men (MSM). This particular issue is being addressed with the Engaging Physicians project, based out of the Living Positive Resource Centre in Kelowna. F BCPWA Advocacy gets results! In smaller communities, where disclosure of HIV status via association is a real concern, many doctors and their patients don’t want their clinic to be identified as the local AIDS clinic. The HIV Care Physician Registry is addressing this concern by not publicly listing the doctors and by housing the registry at BCPWA. There are still too many doctors who won’t see HIV-positive people for a variety of personal and religious reasons—an unacceptable reality that we’re hoping to address with education and the promotion of the HIV Care Physician Registry. With assistance from the BC-CfE and the provincial HIV/AIDS public health nurses, we have currently recruited and registered 60 physicians for the registry. But 41 of the 60 doctors are in Metro Vancouver; there are clear deficiencies in the north and in other geographic pockets in the province. In order to overcome these challenges, BCPWA will need to work with physicians, nurses, AIDS service organizations, and PWAs to continue to expand the registry, to ensure that person living with HIV in BC has access to a qualified physician. 5 Recommend doctors for the registry If you can recommend a doctor for the HIV Care Registry, visit the registry page on the BCPWA website at www.bcpwa.org/empower_yourself/physician or call 604.646.5366, or toll-free at 1.800.994.2437 ext. 366 Neil Self is an advocate in BCPWA’s Treatment and Information Advocacy Department and an MSW student at the University of British Columbia. The BCPWA Society’s Advocacy Program continues to work hard to secure funds and benefits for our members. The income secured for June 2008 and July 2008 is: $28,155 in debt forgiveness. t $2,800 in housing, health benefits, dental and t long-term disability benefits. $120 in monthly nutritional supplement benefits. t $2,700 in ongoing monthly nutritional supplement t benefit for children 16 living5 SeptemberqOctober 2008 *nformation issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 17 treatment TREATMENT INFORMATION PROGRAM MANDATE & DISCLAIMER In accordance with our mandate to provide support activities and facilities for members for the purpose of self-help and self-care, the BCPWA Society operates a Treatment Information Program to make available to members up-to-date research and information on treatments, therapies, tests, clinical trials, and medical models associated with AIDS and HIV-related conditions. The intent of this project is to make available to members information they can access as they choose to become knowledgeable partners with their physicians and medical care team in making decisions to promote their health. The Treatment Information Program endeavours to provide all research and information to members without judgment or prejudice. The program does not recommend, advocate, or endorse the use of any particular treatment or therapy provided as information. The Board, staff, and volunteers of the BCPWA Society do not accept the risk of, or the responsibliity for, damages, costs, or consequences of any kind which may arise or result from the use of information disseminated through this program. Persons using the information provided do so by their own decisions and hold the Society’s Board, staff, and volunteers harmless. Accepting information from this program is deemed to be accepting the terms of this disclaimer. An issue that’s coming of age The population of people with HIV is getting older, which raises a slew of new and unexplored concerns by Adriaan de Vries ately, there’s been a lot of talk about aging while living with HIV. Not long ago, the very idea was considered an oxymoron, and thus not worthy of discussion. However, the population of PWAs has changed dramatically in the past 12 years—and continues to change. In 2005, only 6 percent of Canadians who tested positive for HIV were 50 years of age or older. In L SeptemberqOctober 2008 living5 2008, 19 percent of newly diagnosed people were 50 or older. Statisticians predict that within 10 years, 20 percent of all Canadians living with HIV will be 50 or over. Why should we pay attention? What makes age important enough to warrant special attention from the medical community as well as people living with HIV? For starters, studies have found that untreated 17 continued on next page issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 18 older HIV-positive individuals are twice as likely to die than their untreated younger counterparts. A number of issues factor into these age-related differences. First is the issue of diagnosis. People over the age of 50 have very different and often unrecognized barriers to being diagnosed for HIV disease. They have significant barriers to accessing prevention information and education, which is largely targeted to younger age groups—those considered more sexually active, more involved with recreational drugs, and more involved in youth culture activities such as tattooing. We tend to approach older people differently. Doctors are less likely to ask older patients about high-risk behaviours or to suspect the possibility of HIV in their patients. They don’t review their sexual histories and risk behaviours as frequently, and thus are less likely to talk about safer sex practices or get tested for HIV. Older people also tend to be less comfortable discussing their sexual lives and asking for an HIV test. To further complicate matters, many symptoms and conditions related to aging are common to those related to being HIV-positive. Pulmonary and heart problems are common to both, especially to those with a history of smoking and other lifestyle factors. Stamina and immune function are often decreased in the elderly. People’s faces become thinner, and they develop hypertension. If a doctor doesn’t test for HIV antibodies, these symptoms may be attributed to age. As a result, HIV isn’t diagnosed, monitored, or treated, even though it may be necessary to do so. An important factor in treatment is knowing whether symptoms are HIV- or age-related. Choosing the wrong treatment means the treatment could cause unknown, possibly negative results. Older patients also have a greater likelihood of experiencing toxicity with HAART medications. CD4 and viral load test responses can be different: older people develop less CD4 cells than younger people as a normal part of aging. When on HAART, older people increase their CD4 count more slowly than their younger counterparts and reduce their viral load less quickly. To complicate matters, many symptoms and conditions related to aging are common to those related to being HIV-positive. Not a lot is known about aging with HIV, simply because we have never had to be concerned about people living longer than 25 years with HIV. Furthermore, many HIVpositive people over 50 need both HAART and medications for conditions related to aging. The interactions of those combinations are not yet well understood. Research is just beginning in this area. In future issues of living 5, we’ll explore specific HIV and aging issues, such as cardiovascular health, cancers, bone and liver health, hypertension, and mental health concerns such as depression and dementia. 5 Adriaan de Vries is the director of BCPWA’s Treatment Information and Advocacy Department and has been involved with HIV issues since 1983. We need people like you. BCPWA has volunteer opportunities in the following areas: HIV+ Women Volunteers Needed>knowledge of HIV, medications, tests, health treatment issues. Interested in obtaining speaking and/or workshop development skills? Second Hairstylist>Volunteer hairstylist needed to provide professional haircutting and styling at our own in-house salon Lounge Host >Serve coffee, tea, juices and pastries to members Polli & Esther’s Closet Assistant >Help in a free clothing store that provides clothing and small household items to members Special events >AccolAIDS Awards Gala and AIDS WALK for LIFE Writers > living5 magazine, Communications volunteer @ BCPWA Benefits of becoming a volunteer: ◆ Make a difference in the Society and someone’s life ◆ Gain work experience and upgrade job skills ◆ Find out more about HIV disease If you are interested in becoming a volunteer and/or to obtain a volunteer application form, please email [email protected], call 604.893.2298 or visit www.bcpwa.org. 18 living5 SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 19 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 20 Feature Story Undetectable vs. uninfectious Swiss experts announced that PWAs with undetectable viral loads were “sexually uninfectious.” Other worldwide authorities called the statement premature. Who’s right? by Derek Thaczuk was the Swiss shot that was heard around the world. In January 2008, Swiss HIV experts stated that HIV-positive individuals could be considered “sexually non-infectious,” as long as they were on effective antiretroviral treatment and free of other sexually transmitted infections. The statement—authored by four of Switzerland’s foremost HIV experts and published in the Bulletin des médicins suisses—proclaimed that “an HIVinfected person on antiretroviral therapy with completely suppressed viraemia [i.e., with an undetectable viral load] is not sexually infectious, i.e. cannot transmit HIV through sexual contact.” With this confident, unprecedented claim, the Swiss experts threw an abrupt curve at previous prevention messages—all of which had stressed just the opposite: that undetectable viral load did not equal the absence of transmission risk. This caution had stemmed from several reasons, first and foremost, the consequences of being wrong: one new infection due to undue optimism equals one more person with HIV. Secondly, viral load levels can differ between the blood and other body fluids. While lower viral RNA in blood usually also means lower RNA in sexual fluids, the amounts are not equal: HIV in semen, vaginal fluids, and rectal tissue can be measurable even if undetectable in the blood plasma. Even “undetectable” merely means that viral RNA is present in smaller amounts than current tests can detect; it doesn’t mean it’s completely absent. Finally, any number of other factors could potentially affect a person’s likelihood of infectiousness, notably, having other sexually transmitted infections is known to increase the risk of passing HIV to sexual partners. (A fact that was acknowledged in the Swiss report.) It 20 living5 SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 21 Feature Story What, then, led the Swiss commission to make such a bold leap? What were they thinking? Evidence for Antiretroviral treatment does greatly reduce HIV transmission risk in two other settings: childbirth and breastfeeding. When an HIV-positive mother’s viral load is reduced by antiretroviral therapy, transmission risk during delivery and birth is greatly lowered as well. Treatment for HIV-positive mothers around the time of delivery (now routine practice) has drastically reduced rates of HIV transmission to newborns. Studies have also repeatedly found that breastfeeding children of HIV-positive mothers are much less likely to become infected when the mother is on highly active antiretroviral therapy (HAART). What about transmission between sexual partners? Relatively few studies have investigated the question, largely since controlled studies would be ethically impossible. (Clearly, you can’t instruct mixed-status couples to have unprotected sex, just to see how many negative partners get infected. Trials of preventive vaccines face a similar challenge.) However, a small but growing number of uncontrolled observational studies have associated lower viral load with lower sexual transmission risk. A study published in 2000 analyzed 415 serodiscordant heterosexual couples—those with one HIV-positive and one HIV-negative partner—in Uganda. The highest rates of HIV transmission—23 new infections per 100 person-years—occurred when the HIV-positive partner’s viral load was above 50,000 copies/mL. At lower viral loads, between 400 and 3,499 copies/mL, infections were just a tenth as frequent, at 2.2 cases per 100 person years. Most strikingly, no new HIV infections were seen in couples where the HIV-positive partner’s viral load was below 1,500 copies/mL. At least three other studies of serodiscordant heterosexual couples reached similar conclusions, finding no infections in the partners of HIV-positive people on HAART with undetectable viral loads. These included a prospective Spanish study of 393 couples between 1991 and 2003, a prospective Brazilian study of 92 couples, and a retrospective Spanish study of 62 couples who were trying to conceive children through unprotected intercourse. The Swiss analysis also referred to studies of HIV in semen and vaginal fluids, noting that viral load in both semen and vaginal fluids generally decreases during HAART treatment, and that viral load in the female genital tract is generally lower than that in blood plasma. They also argued that, even when HIV RNA can be found in semen, it does not necessarily indicate that infectious virus is also present—an argument somewhat like saying that a gun “might not” be loaded. The Swiss team concluded that “all epidemiological and biological data indicate that there is no relevant risk of transmission during ART which is completely adhered to” on the basis of all the above evidence—a conclusion that many others challenged. Evidence against Naturally, the Swiss statement came with certain caveats. The need for HAART adherence, sustained undetectability of viral load (for at least six months), and lack of other sexually transmitted infections were clearly called for. But several other counterarguments were raised in the ensuing criticism. Most importantly, other world experts have stressed that the report’s conclusion is based on interpretation and opinion, not conclusive evidence. The argument for non-infectiousness hinges on the trust that undetectable viral load in the blood means no infectious virus in the semen or other sexual tissues. Studies have in fact found that effective antiretroviral treatment most often leads to an undetectable HIV viral load in blood, semen, and vaginal fluids—but not necessarily at the same time. It’s entirely possible to have significant viral load in sexual fluids while the viral load is undetectable as measured by blood. Several studies have found significant virus in semen after the six-month “undetectable” period recommended by the Swiss. The Swiss team concluded that “all epidemiological and biological data indicate that there is no relevant risk of transmission during ART which is completely adhered to.” Even if undetectable plasma viral load would be a completely reliable measure of infectiousness, there is still the matter of blips—short-lived increases in viral load to detectable levels that are sometimes seen in people on successful HAART. Since these blips can appear unpredictably, there is no guarantee that a person’s viral load is undetectable at any given time, even if it was undetectable at the time of last measurement. The same argument could apply to sexually transmitted infections (STIs): if you’ve been sexually active, how certain can you be that you have not picked up an STI since your last negative test? Finally, one of the statement’s biggest shortfalls was its failure to address gay men and anal sex. As more than one community advocate has put it, “one hole is not the same as the next.” More scientifically, there are significant differences between the tissues of the vaginal tract and the rectum. Since the studies cited in the Swiss statement were conducted in heterosexual couples, their interpretations cannot be applied to gay men. (Some studies in gay men, such as the San Francisco Men’s Study, have shown declining HIV incidence since the introduction of HAART, but this is a very far cry from conclusive evidence.) As yet, there is no assurance that an undetectable viral load equals lack of sexual infectiousness for gay men. And there is certainly no indication of what an undetectable viral load might mean for injection drug users. continued on next page SeptemberqOctober 2008 living5 21 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 22 Crucially, many critics stress that terms like “uninfectious” and “zero risk” are misleading, and the report itself admits that such terms need careful interpretation. The authors admit that the medical and biological data do not permit “strict scientific proof” that infection during effective HAART is strictly impossible. They liken the claim to the argument that “HIV cannot be transmitted by kissing”—not indisputably proven, but compelling enough to be taken as fact. This is where agencies and AIDS groups around the world beg to differ. Granted, safer sex guidelines, including the Canadian AIDS Society’s, contain a “minimal” or “theoretical” risk category. This category is reserved for activities like kissing, where actual cases of transmission have never been observed, and the theoretical chance is astronomically slim—if not unequivocally “zero.” Most experts argue that it’s a question of the burden of proof. Kissing can reasonably be assumed to be safe unless and until the unlikely event that someone proves otherwise. Unprotected sex during treatment, on the other hand, should be considered unsafe until a great deal more evidence consistently shows otherwise. Treatment as prevention: a population point of view The Swiss statement was, in fact, not the first take on the question of treatment as prevention, even if it was the most dramatic. One of the leading researchers to put the treatment as prevention issue on the map was the BC Centre for Excellence in HIV/AIDS’s own Dr. Julio Montaner. In a commentary recently published in the Canadian Medical Association Journal, Dr. Montaner and colleagues argue that, since HAART has been shown to reduce the rates of HIV transmission, expanding treatment to the HIV-positive population could serve as a prevention tool to curb the rates of new infections. Opponents of this view point out that what works at a population level doesn’t necessarily make good individual advice. This distinction has been much discussed in the context of preventive vaccines, which are unlikely to be completely protective. Think of a vaccine that you knew to be, let’s say, 90 percent protective against HIV. On a world scale, that might result in hundreds of thousands of averted infections. But if you were HIV-negative, would you personally rely on it to protect you the next time you had sex? Somewhat surprisingly, Switzerland has one of the world’s most punitive legal environments toward sexual transmission of HIV. In Canada and many other countries, HIV-positive people are generally safe from criminal charges as long as they clearly disclose their status to sexual partners before sex takes place. Not so in Switzerland, where charges can still be laid against an HIV-positive person for having unprotected sex, even with full disclosure and consent. It has been suggested that the Swiss statement was meant to work against these frightening legalities. (The authors themselves state that one of their objectives was to “alleviate fears of people living with or without HIV, and thus to allow…people living with HIV in Switzerland to live as ‘normal’ as possible a sexual life.”) 22 living5 Whether this strategy will have any success—in Switzerland or elsewhere—remains to be seen. To our knowledge thus far, no arguments based on viral load and infectiousness have been brought forward in a legal case concerning HIV transmission. At present, there is no indication whether any of the arguments used in the Swiss statement would carry legal weight in a Canadian, Swiss, or any other court. The need for clear messages The complexities and confusions of the Swiss debate have made one thing clear: while information shouldn’t be dumbed down for public consumption, it does need to be as clear and consistent as possible. Most people don’t have the time or resources to follow the fine print: they need to know whether “this is safe” or “this isn’t.” Changing information has led to other confusing flip-f lops in prevention messages in the past, and likely will again. In the meantime, we have a shared responsibility to inform people as clearly as we can. The “uninfectious” debate will likely remain heated and highly polarized for some time to come. On the one hand, a message of such magnitude needs to be endorsed by more than the considered opinion of one expert group—it needs rocksolid evidence that can be widely agreed upon. On the other hand, with vaccines and microbicides still a distant and uncertain hope, alternatives to a lifetime of condoms are sorely needed—not just for couples who want to raise children, but the millions of sexually active people living with or at risk for HIV. One point that has gotten a bit lost in all the scientific debate is that people with and at risk for HIV are starving for the kind of good news that the Swiss statement represented. Imagine a world in which HIV-positive people could have unprotected sex—freely, safely, and without fear of infecting their partners or suffering legal consequences. We need more than reasons why that isn’t a reality—we need to make it a reality. 5 The world weighs in The Swiss statement has been almost universally criticized by other experts worldwide. Two informative analyses are: q The Australasian Statement on HIV Antiretroviral Therapy and Infectiousness, www.ashm.org.au/news/334/11/ q The Canadian AIDS Treatment Information Exchange (CATIE)’s “Swiss guidelines take a troubling turn”, www.catie.ca. (Search the site for “Swiss”, under “CATIE news.”) Derek Thaczuk has worked in information and support services within the HIV community for over a decade and is now a freelance writer and editor. SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 23 Let’s get clinical! Taking a shot at the flu W by Jennifer Chung ith a flu pandemic expected to occur in the next five to 10 years, being ready to provide timely care— especially to those with compromised immune systems—is essential. Canadian researchers have risen to the challenge by rolling out a study examining vaccine strategies in HIV-infected people [CTN 237]. “The burden of influenza disease among patients living with HIV, including those who have been previously vaccinated, is actually quite high in Canada and elsewhere,” says study principal investigator Dr. Curtis Cooper of the Ottawa Hospital. “For this population, the illness is more severe, the duration is longer, it results in more hospitalization, and there’s a slight increase in mortality.” Over the coming months, and in advance of flu season, participants will be randomized to one of three groups. Group one will receive a single injection of Fluviral, group two will receive an injection of Fluviral followed 30 days later by a second booster, and group three will receive a double dose of Fluviral followed 30 days later by a second double dose of Fluviral. Researchers believe that if the booster dose of influenza vaccine results in improved seroprotection and eases disease burden, it will be valuable in treatment guidelines for flu vaccination in people living with HIV. “It’s been a long-standing recommendation that all HIVinfected persons receive a flu shot every year. It turns out we aren’t quite sure that it’s effective,” says Dr. Brian Conway, director of the Downtown Infectious Diseases Clinic, the BC site that will be recruiting participants for this study. Conway explains that in some individuals such as women, older people, and those with lower CD4 counts, a different strategy may be needed to maximize the benefit of f lu shots. “This study will allow us to compare different approaches to the yearly f lu shot and demonstrate which is best for our patients.” Dr. Cooper says that early planning might enable future trials to be conducted quickly through the network of trained sites developed from this one study. “It’s vital that if we’re in the middle of a pandemic, we’re able to recruit patients rapidly to evaluate new vaccines, he says. “Much of the data collected will allow us to understand why people do or don’t participate in inf luenza vaccine studies.” Dr. Cooper explains that findings from this study could also help others with compromised immune systems. “We’re eager to see if results from this study might be applicable to other populations including those on steroids as well as people living with autoimmune disease, organ transplantation, and cancer.” CTN 237 is aiming to recruit 285 people at 10 sites in Canada. The study is expected to roll out in early fall. 5 Jennifer Chung is the information and communications coordinator at the Canadian HIV Trials Network in Vancouver. Trials enrolling in BC CTN 239— CTN 233— CTN 222— Phase II study of AGS-004 an immunotherapeutic agent in combination with ART followed by ART interruption BC sites: St. Paul’s Hospital, Vancouver Pharmacokinetics of antiretroviral therapy (ARV) in HIV-positive women BC sites: Downtown Infectious Diseases Clinic (DIDC), Vancouver; St. Paul’s Hospital, Vancouver; Children’s and Women’s Hospital, Vancouver Canadian Co-infection Cohort BC sites: DIDC, Vancouver; St. Paul’s Hospital, Vancouver SeptemberqOctober 2008 CTN 214— CTN 194— Effect of a One-Year Course of HAART in Acute/Early HIV BC sites: DIDC, Vancouver; Cool Aid Community Health Centre, Victoria Peg-Interferon and Citalopram in Co-infection (PICCO) BC sites: St. Paul’s Hospital, Vancouver, DIDC, Vancouver To find out more about these and other CTN trials, visit the Canadian HIV Trials Network database at www.hivnet.ubc.ca or call 1.800.661.4664. living5 23 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 24 Antiretrovirals Antiretroviral update The BC Centre for Excellence’s June presentation by R. Paul Kerston he BC Centre for Excellence in HIV/AIDS (BC-CfE) held their semi-annual antiretroviral update in early June. There were a number of highlights. BC-CfE’s director, Dr. Julio Montaner, presented 48-week results from the CASTLE study showing that once-daily atazanavir (Reyataz) boosted with ritonavir (Norvir) appears as good as twice-daily soft gel capsules of ritonavir-boosted lopinavir (Kaletra) in suppressing HIV, with very minor differences in CD4 increases between them. The study looked at 883 treatment-naïve patients having viral loads greater than or equal to 5,000, and dosing included emtricitabine (FTC, Emtriva) and tenofovir/emtricitabine (Truvada) once daily. Dr. Montaner suspects that maraviroc (Celsentri)—in a new class of drugs called CCR5 co-receptor antagonists—while approved for treatment-experienced patients in Canada, might be used for first-line therapies in future. Unfortunately, maraviroc can easily become ineffective for a number of reasons. Notably, Dr. Montaner mentioned there were only seven cases of protease inhibitor (PI) class resistance in all of BC during 2007, showing how effective antiretroviral treatments can be with good adherence. He also mentioned that new blips in low-end viral load results—which might truly be less than 40 copy results but sometimes read higher with the new test—shouldn’t be ignored and the test should be retaken, just to be safe. Dr. Montaner urged physicians whose patients present with opportunistic infections (OIs) to immediately treat with antiretrovirals, regardless of current CD4 cell counts. Raising CD4 T 24 living5 levels through successful viral treatment helps ensure against OIs. The recommendation is also based on results from Study ACTG A5164, presented at Conference on Retroviruses and Opportunistic Infections (CROI) this year. New BC-CfE treatment guidelines should be available in September 2008, with the newer Atripla (a three-in-one, once-aday combination of emtricitabine, tenofovir, and efavirenz) plus Kivexa or Truvada as a preferred first-line regimen, and atazanavir/ritonavir, Kaletra, or boosted saquinavir (Fortovase), in other first-line recommended combinations. Advanced treatment options will probably favour efavirenz (Sustiva) over Kaletra for those with equal to or greater than 200 CD4 cell counts. Women and side effects of Truvada Dr. David Burdge, from the Oak Tree Clinic, presented on HIV infection in women. He noted he’s seen more women than men experiencing side effects with Truvada, which can include nausea, vomiting, and rashes, usually within the first week. Women who are able to adhere to treatment do as well as men on this drug, however. He suggests that lamivudine (3TC) with tenofovir produces fewer side effects, generally, and he added that tenofovir appears good for women’s overall bone health. Dr. Burdge thinks DEXA bone density scans will soon become a part of BC-CfE guidelines at baseline, meaning they would be part of an initial screening upon HIV diagnosis. Junine Toy, a clinical pharmacist at St. Paul’s Hospital, talked about how the pharmacy noticed that protease inhibitors (PIs) and even tenofovir-based regimens may produce SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:32 PM Page 25 gas. She gave strategies for controlling gas and other relatively minor but annoying side effects such as diarrhea: avoiding ritonavir, nelfinavir, and Kaletra; abstaining from caffeine, alcohol, sorbitol, and high-sugar beverages; going easy on greasy or spicy foods, plus dairy products; and using both prescription and non-prescription medications, including psyllium, calcium, loperamide (Imodium) and lactase. She gave similar advice for flatulence, cramps, nausea, and vomiting. She also offered ideas for controlling the central nervous system effects of efavirenz, and she urged against doing treatment interruptions with efavirenz because of its long half-life. Toy also mentioned that atazanavir has been associated with increases in blood levels of bilirubin, a product of the breakdown of aging red blood cells, and found in the liver before typical excretion. In excess levels, this indicates jaundice. She said that minor increases in bilirubin can be tolerated. Baseline assessments for hepatitis B Dr. Zig Erb, from the Department of Gastroenterology at Vancouver General Hospital, gave a presentation on baseline assessments plus treatments for hepatitis B (HBV). He also stressed doing resistance testing for HBV drugs at baseline and whenever changes are anticipated. Repeatedly, Dr. Erb stressed that HBV RNA is the best assessment of HBV infection, and said that if the RNA test is positive, treatment should begin. He stressed that HIVnegative persons with HBV RNA positive results (as well as HIV-positive persons not on HIV treatment) should always be treated for HBV. He suggests using two classes of HBV medications, including either lamivudine or emtricitabine plus a class 2 HBV drug, if the person is HIV-positive; if HIV-negative, then he said to consider using pegylated interferon (Pegasys) and not lamivudine or emtricitabine. Finally, Dr. Erb pointed out that interferon, for six months, is paid by MSP. Dr. Richard Crawford, from the Division of Dermatology at St. Paul’s Hospital and an affiliate of the Immunodeficiency Clinic at the BC-CfE, talked about various skin disorders affecting HIV-positive persons, including molluscum, eosinophilic folliculitis, and rashes. He also suggested some treatment options, including the new PI darunavir (Prezista), in addition to nevirapine, which have some risk for the potentially fatal Stevens-Johnson syndrome. Dr. Crawford suggests that treatment with topical corticosteroids is effective, but stressed that the potency of the drug selected is more important in determining effectiveness than the drug’s concentration in the medication. (The old test only measured up to 100,000 and down to 50.) This test requires a greater volume of blood than previously needed and some results are coming back as “insufficient volume: no result.” Dr. Harrigan said he would advocate for greater volume in those blood draws, and he urged patients to do the same. Dr. Harrigan also spoke about the new CCR5 tropism assay he is developing. This test is needed to determine susceptibility to maraviroc, but testing is currently only done in a San Francisco laboratory. Limitations of this assay include the need for 5 ml of blood that has been freshly processed (not frozen) and the viral load must be at least 1,000 copies. Therapeutic drug monitoring Dr. Marianne Harris, the clinical research advisor for the AIDS Research Program at St. Paul’s Hospital/University of British Columbia, addressed how therapeutic drug monitoring (TDM) isn’t standard of care and can only be used with PI medications and non-nucleoside reverse transcriptase inhibitors (NNRTIs), not with nucleoside reverse transcriptase inhibitors (NRTIs). TDM requires a patient’s informed consent and currently must be performed at St. Paul’s Hospital. TDM can establish whether drug levels in the blood are too low or too high or within therapeutic range, but Dr. Harris stressed that it isn’t yet an exact science because the timing of the peaks and troughs relative to the blood draw aren’t fully known yet, thus results may not be accurate. It’s still experimental. Physicians may request TDMs through Dr. Montaner or Dr. Harris. Additionally, Dr. Harris mentioned that there are 14 cases in medical literature concerning kidney stones associated with atazanavir, which don’t appear to be related to drug concentration levels. Finally, Dr. Montaner presented several slides showing how considering HIV as a chronic inflammatory disease explains not only the CD4 cell loss but also the causes of HIV-related (but non-AIDS) events such as heart, liver and kidney problems, plus cancers. 5 Watch the presentation on video To watch the entire antiretroviral update on video, visit the BC-CfE’s website at http://cfenet.ubc.ca/video.php?id=23&sid=33&cat=57. New viral load assay Dr. Richard Harrigan, the director of Research Laboratories at the BC-CfE, spoke about the new viral load assay that measures HIV RNA. Developed by Roche, the new test, called the TaqMan, measures up to 1,000,000 copies and down to 40 copies. SeptemberqOctober 2008 R. Paul Kerston is BCPWA’s treatment outreach coordinator and community representation and engagement (CRE) coordinator. living5 25 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 26 Nutrition Better safe than sorry Know how to keep your food free of bacteria and protect yourself from food-borne illness by Sarah Fielden and Shemina Patni arlier this year, tomatoes were pulled from grocery store shelves and removed from the menus of restaurants across North America. The culprit: Escherichia coli (E-coli), bacteria that live in humans and the bodies of other animals but can be toxic if consumed in high levels in contaminated food. E-coli and other bacteria such as Campylobacter, Salmonella, and Listeria can f lourish in foods produced and consumed in unsafe conditions. These, in turn, produce food-borne illnesses that can be accompanied by symptoms that range from mild (nausea) to severe (meningitis). And yes, you should care: HIV-positive people are more susceptible to food-borne illness than other people with stronger immune systems. In the food service industry, certain steps in producing and distributing foods have been identified as critical control points for ensuring that food remains safe from farm to plate. Safety plans are put into place according to guidelines and models such as HACCP (Hazard Analysis and Critical Control Points). These steps are comparable to the safety process that you should follow when purchasing food and preparing it at home. The following suggestions will help to keep you safe from food-borne illness at each step. E 26 living5 Purchasing q Buy only pasteurized dairy products, ciders, and juices. q Avoid dented cans, broken seals, and other signs of damage. q Avoid bruised produce—it has begun decomposing prematurely at those spots. q Check the expiry date of items before you buy them. q Make sure you rotate foods such as eggs in your fridge so that you eat the less fresh items first (as long as they are still good). q Minimize the time from store to fridge for refrigerated and frozen items—buy them last and bring them directly home. q Avoid raw foods—such as sushi, some desserts made with raw eggs—that are sold in the grocery store and at restaurants. Thawing q Thaw foods in your fridge or, if necessary, under cold running water, rather than on your kitchen counter. Bacteria thrive in warm moist environments. q Thaw items on plates in your fridge, so raw juices don’t contaminate other foods; this is called cross-contamination. Preparation q Make sure surfaces, cutting boards, utensils, and serving dishes are clean. Dishes should ideally be cleaned in water that is SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 27 HIV-positive people are more susceptible to food-borne illness than other people with stronger immune systems. 180F/82C (steaming) temperature. Surfaces should be bacteria free (you can use a solution of 1 teaspoon of bleach to 1L of water as a cheap alternative to expensive cleaners). q Wash fruits and vegetables with running water, rubbing them or scrubbing them to get rid of surface bacteria. q Use different cutting boards for meats, dairy, and produce; try different colours. Plastic cutting boards are easiest to keep clean. q Wash your hands before preparing food and often throughout, especially when handling raw meats. q Use clean washcloths and sponges and replace them regularly. q If in doubt about a food’s quality, throw it out. q Cook all meats, poultry, eggs, and fish to the well-done stage. There should be no pink in meats, egg yolks should be firm, and juices of chicken should run clear. A thermometer should reach 180°F (82°C) for chicken and 160°F (71°C) for burgers. Most cookbooks will tell you proper cooking temperatures and techniques. q Avoid cross-contamination by keeping raw and cooked foods separate during preparation. q Leave microwaved items to sit out of the microwave for a few minutes in order to finish cooking. SeptemberqOctober 2008 Holding and storage q Keep hot foods hot (over 140°F/60°C) and cold items cold (under 40°F/4°C). q Don’t leave foods sitting at room temperatures for more than two hours if they’re not shelf stable, that is, foods that can be stored on the shelf like dry grains. q Don’t leave raw meats in the fridge for more than 2 days. q Store food items in sealed containers in and outside of the refrigerator. q Don’t keep leftover foods for more than two days after they’ve been prepared. q Reheat leftovers only once to a steaming temperature over 165°F (74°C). 5 Further reading For more information about food-borne infection and precautions, read “Spoiled rotten,” living 5, September/October 2005. Sarah Fielden is a member of Vancouver Dietitians in AIDS Care and is completing her PhD at the University of BC in Interdisciplinary Studies at the Centre for Population Health Promotion Research. living5 27 Shemina Patni is a registered dietitian and works for Morrison Healthcare Food Services as a patient food services manager at the Children’s and Women’s Health Centre of B.C. issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 28 Side Effects The two faces of Bio-Alcamid New study reports some immune-related side effects from the facial filler by Zoran Stjepanovic here has been some news recently about people having immune-related side effects many months after having been injected with facial filler polyalkylimide gel, or Bio-Alcamid. This raised some eyebrows at BCPWA because we’ve been advocating for medical insurance coverage of this injection for people living with HIV. Facial lipoatrophy, or facial wasting, is a direct side effect of HIV medications or HIV itself. This debilitating and disfiguring condition can have a detrimental effect on a person’s self-esteem, causing the person to become isolated and even more stigmatized. As a result, many individuals develop clinical depression and they may have difficulty functioning in daily life. Bio-Alcamid’s treatment for facial lipoatrophy was approved by Health Canada in 2006. It’s a filler implant that comes as a transparent gel in sterile syringes, and is permanent—though it can be removed if necessary. Known potential side effects may include pain, swelling, bruising, or redness that can occur in the first few days after being injected. These side effects usually go away. There have not been any reports of the immune system reacting to Bio-Alcamid. However, recently a study was published in the Archives of Dermatology reporting problems with Bio-Alcamid. Spanish physicians from Barcelona assessed 25 people who had what appeared to be side effects of Bio-Alcamid injections 12 months or more after treatment. The side effects ranged from tender modules or bumps at the injection site in 24 of the 25 participants, and headaches and fever in six participants. Twenty individuals had laboratory abnormalities that implied immune inflammation. Note, however, that this was a very small study and the study didn’t indicate whether participants were HIV-positive. Since these study results were released, Ascente Medical Corporation has responded by stating that the rate of delayed adverse events with Bio-Alcamid is extremely low and also T 28 living5 comparable to the average rate of occurrence among other facial fillers, including hyaluronic acids (Restylane) and polylactic acids (New Fill/Sculptra). They claim that between 2001 and 2006, over 190,000 mLs of Bio-Alcamid were sold in Spain and approximately 2mL to 5mL were used for each treatment— meaning that somewhere between 32,200 and 80,200 patients were treated. Based on the number of treatments, delayed adverse events occurred in only 0.04 percent to 0.10 percent of patients. It was a very small study and the study didn’t indicate whether participants were HIV-positive. The manufacturers also argue that Bio-Alcamid wasn’t compared to other facial fillers in terms of delayed adverse events, and that a 2007 study also showed delayed adverse effects related to hyaluronic acid and acrylic hydrogel dermal fillers; in that study, investigators found an occurrence of delayed adverse effects at 0.05 percent. BCPWA has been advocating with the Ministry of Health to get medical services coverage of this product for people with HIV based on the argument that it’s reconstructive surgery, and not a cosmetic procedure used to alleviate symptoms of HIV disease. Expect to hear about these advocacy efforts in the near future, as well as more detailed information on different treatments used to treat facial lipoatrophy in future issues of living 5 magazine. Zoran Stjepanovic is BCPWA’s treatment information coordinator. SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 29 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 30 Complementary Therapies Spice up your life Turmeric, ginger, and garlic don’t just add flavour, they have healing qualities by Alix Mathias hat’s hot, tasty, and gets your blood pumping? Todd Caldecott, clinical/medical herbalist, Ayurvedic practitioner, and author of Ayurveda: The Divine Science of Life, shares his wisdom on the use of herbs and spices for healing. Caldecott volunteers at the Vancouver Friends For Life Society, teaching group classes on how to apply the ancient healing art of Ayurveda in your wellness journey. W Alix Mathias: What are your three favourite medicinal or healing herbs and spices? Todd Caldecott: It’s very difficult for me to narrow it down to just three, but I choose turmeric, garlic, and ginger. AM: What are these spices traditionally used for? What are their healing properties? TC: Turmeric is a cooling, bitter-tasting, detoxifying remedy that helps to promote bile flow in the liver, cleans the blood, purifies the skin, and reduces inflammation. It’s used to treat most types of liver disorders, particularly if there is congestion or obstruction of bile flow. Turmeric speeds up and enhances the filtering of blood, which benefits the skin so it is very helpful for conditions like eczema and acne. The yogis of India have 30 living5 traditionally used it to strengthen and nourish the ligaments and reduce inflammation in the joints. Garlic is a heating, pungent-tasting, detoxifying herb that helps to strengthen digestion and boost the immune system. It’s believed to have vascular [i.e., the tubes that carry your blood] benefits, normalizing blood lipids and improving blood circulation. Garlic is seen as rejuvenative and restorative, and is taken by people recovering from chronic illness, or post-partum, to boost their vital energy. In this case, garlic is better cooked in a meat broth, boiled in milk, or roasted to remove its pungent, aggravating properties. Ginger is another important herb, with a heating, pungent f lavour that similarly strengthens digestion and moves the blood. In Ayurveda, ginger is called dipanapachana, meaning that it stimulates the appetite while providing a cooking activity, helping to transform foods into nutrients in the gastrointestinal system. Ginger is widely used to alleviate cramping and is particularly useful in nausea. Ginger is mixed with honey to get rid of excess mucus and congestion, and is also good to promote circulation. Taken on its own, or with herbs such as turmeric, ginger is useful for joint pain. SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 31 AM: How can those of us who didn’t grow up with these herbs and spices learn how to start making better use of them in our daily lives? TC: Garlic is the easiest to incorporate into your diet because it tive effect in the liver, and can be combined with other herbs to support the liver. can be added to most any dish. It’s best eaten fresh, mixed with a little fatty food such as avocado to minimize its pungent quality. On less appetizing subjects, a poultice of garlic is very good to draw pus out of abscesses and treat infections, and when crushed and mixed with oil can be used as a suppository for parasites like pinworms. Raw garlic infused in honey is another combination, and is a very good cold, flu, and cough remedy. Turmeric should be used in small amounts; maybe 1/4 teaspoon per person per dish, otherwise it lends too bitter of a flavour. It can be added to the water of grains like rice or quinoa to give it a brilliant yellow colour. Turmeric can be boiled in some organic milk as an effective remedy for coughs and bronchitis. Mixed with a little salt and water, turmeric is also a good gargle for sore throats. Turmeric has definite antimicrobial properties, and can be applied topically and taken internally for infection, and works very well for parasites and fungal infections. Tea made with fresh, boiled ginger is fantastic to drink in the cold season and will help ward off colds and flus. Ginger can be added to the water when boiling dry beans to ensure they don’t cause flatulence. although what is aphrodisiac to one person may not be for another. Among the commonly used spices, nutmeg is probably the most reputable aphrodisiac. Cardamom is also believed to have mild aphrodisiac properties, and can be combined with nutmeg and other similar herbs such as cinnamon and ginger, boiled in milk, and taken with a teaspoon of ghee and a little sugar. Other common spice cabinet aphrodisiacs include chocolate, vanilla, saffron, and rose. Garlic is another reputed aphrodisiac, and is avoided by some meditators because it inflames the passions. Of course, it works best if both partners consume it, otherwise the libidinous aroma of your partner could just as easily be a turnoff! 5 AM: Where’s the best place to buy these spices? Fresh, whole, or ground—what’s best? TC: It’s best to find them in the whole form, either fresh or recently dried. Fresh turmeric root—rhizome, actually—can typically be found at Indian markets and sometimes at upscale health food grocery stores, but it’s very seasonal. Fresh ginger root can be found everywhere at most times of the year, and the dried whole ginger root can be found at both Indian and Chinese grocery stores. AM: Are there any contraindications? Is there any reason someone who is HIVpositive or has hepatitis C shouldn’t use these spices? TC: For HIV, larger therapeutic quantities of garlic could theoretically promote the premature clearance of protease inhibitors such as ritonavir, by inducing one of the body’s liver enzymes, but not on the same level as something like St John’s wort. I would have no problem, however, suggesting its use in larger amounts for short periods during active infection. There’s no data suggesting that either ginger or turmeric has this action. For hepatitis C, turmeric is of special value, as it helps to support phase II liver detoxification, which helps to remove reactive intermediates produced by phase I reactions. As such, turmeric has a general protective and regeneraSeptemberqOctober 2008 AM: What do you consider the sexy spices? TC: Several spices are believed to have aphrodisiac properties, Golden milk recipe When the weather starts to turn colder, warm yourself with this delicious and healing brew. It will help keep coughs and colds away and your liver will thank you. But wear an apron because turmeric will stain your clothes. 3 1/4-1/2 cup water – add more water if this gets too dry 3 1/8 teaspoon turmeric – you can use as much as 1/2 tsp per cup for a stronger taste 3 3 green cardamom pods (optional) Bring to a boil and simmer 5 to 7 minutes, then add: 3 1 cup milk – raw, organic if you can; goat milk is a good alternative to cow milk if you have an allergy 3 2 tablespoons almond oil; cold-pressed is best Bring the liquid to the boiling point then remove from heat. Don’t allow it to boil. Add honey or maple syrup as desired to taste. Makes one serving. Alix Mathias is a Kundalini Yoga teacher and cheerleader for wellness. She lives a super healthy life, which includes chocolate, ice cream, and coffee because joy is an aspect of wellness. living5 31 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 32 High anxiety HIV and post-traumatic stress disorder can impact one another by Tonya Wood aunting loneliness, desolate isolation—both real and imagined—and an aching emptiness that can seem endless: if you’re living with HIV, you can experience these feelings at any time in your life. Compound those feelings with post-traumatic stress disorder (PTSD) and you could be overwhelmed, confused, and not know where to turn for help. Post-traumatic stress disorder is a new name for a very old condition. In the early twentieth century, it was known as shell shock or battle fatigue. Before that, it had no name. A PTSD diagnosis can have a negative impact on the cause and progression of HIV/AIDS in a number of ways. People H 32 living5 with PTSD tend to report more health problems as compared to people without the disorder. They also tend to engage in more health compromising behaviors, such as alcohol and drug use, smoking, lower levels of physical activity, and poor diets. PTSD is common among PWAs Given the high rate of exposure to traumatic events among people living with HIV/AIDS, it isn’t surprising that many may also have a diagnosis of PTSD. Studies have found rates of PTSD among PWAs to range anywhere from 22 to 64 percent— higher than in the general population. SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 33 How to tell if you have post-traumatic stress disorder You may have post-traumatic stress disorder if: q You experienced, witnessed, or were confronted with an event or events that involved actual or threatened death, serious injury, or a threat to your or another person’s physical integrity, and q Your response involved intense fear, helplessness, or horror Persistent avoidance of stimuli, as indicated by three or more of the following: q Efforts to avoid thoughts, feelings or conversations associated with the trauma q Efforts to avoid activities, places, or people that arouse those recollections of the trauma Signs and symptoms fall under three groups: q Inability to recall an important aspect of the trauma q Persistently re-experiencing the traumatic event in one q Markedly diminished interest or participation in or more of the following ways: significant activities 3 Recurrent and intrusive distressing recollections of the event including images, thoughts, or perceptions q Feeling of detachment or estrangement from others 3 Recurrent distressing dreams of the event q Sense of a foreshortened future (e.g., don’t expect to 3 Acting or feeling as if the traumatic event were recurring (e.g., a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated) 3 Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event q Restricted range of affect (e.g., unable to feel joy) have a career, marriage, children, or a normal life span) Persistent symptoms of increased agitation: q Difficulty falling or staying asleep q Irritability or outburst of anger q Difficulty concentrating q Hyper-vigilance – constantly on the lookout q Exaggerated startle response 3 Physiological reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event An HIV diagnosis itself can cause PTSD symptoms. You may feel as if your life is threatened, and you may experience fear and helplessness. The stigma of an HIV diagnosis may also increase the severity of PTSD symptoms. Studies have found rates of PTSD among PWAs to range anywhere from 22 to 64 percent—higher than in the general population. PTSD can also interfere with adherence to highly active antiretroviral therapy (HAART). Studies have found that this may be due to high levels of depression and distress. Finally, PTSD may negatively affect immune function. Some studies reveal that HIV-positive individuals who have been exposed to a traumatic event show a more rapid decrease in CD4/CD8 cell ratios. There are a number of effective treatments for PTSD. Medications for a primary diagnosis of PTSD vary with each person, and can depend on whether you have co-existing diagnoses. If you have a secondary diagnosis of depression, you may require an antidepressant medication: selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake Inhibiters (SNRIs) are commonly prescribed. Some physicians may treat your anxiety disorder with benzodiazepines—in other words, tranquilizers and sleeping pills. However, if you also have a substance abuse disorder, these medications could be problematic, since they’re potentially addictive. Importantly, all these medications may interact with your HIV drugs. If you do seek a psychiatric consultation and the therapist prescribes something for PTSD, make sure the therapist is aware of which HIV medications you’re taking and is familiar with the possible interactions. 5 Various treatment options If you suspect that you have PTSD, contact your family doctor for referral to a therapist who specializes in anxiety disorders. SeptemberqOctober 2008 Tonya Wood is a volunteer with BCPWA’s Support Services Department. living5 33 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 34 what’s new in research The first Canadian division of AIDS at UBC T by Dr. Marianne Harris he University of British Columbia Department of Medicine established a Division of AIDS (DAIDS) in April 2007. Precedents for a similar DAIDS exist at other major universities in North America, including Harvard Medical School and the University of California at San Francisco General Hospital. The UBC Division of AIDS, based at the BC Centre for Excellence in HIV/AIDS (BCCfE), is the first of its kind in Canada. The Division of AIDS at UBC will bring together faculty and staff members with expertise in epidemiology, basic science, clinical science, HIV prevention, integrated primary and specialty care, urban health, and international health. The advantages of having a DAIDS in Vancouver are many. First, it will enhance collaborations between the BCCfE and the Department of Medicine at UBC. As well, the formal acknowledgement of HIV/AIDS as an academic discipline will allow new physicians and researchers to focus their careers specifically on this area of study, which has previously been encompassed as a subspecialty within the Division of Infectious Disease. Finally, the DAIDS will attract and retain staff with the wide range of expertise needed to further enhance HIV/AIDS clinical care, scientific research, and training in BC. The effort to establish a DAIDS at UBC was spearheaded by Dr. Julio Montaner, who serves as head of both the BCCfE and the DAIDS. Dr. Montaner is well known locally for his leadership in HIV patient care in BC. He’s also recognized nationally and internationally for his important contributions to innovative research in the global fight against HIV/AIDS. The profile of the BCCfE and the UBC DAIDS will be further enhanced now that Dr. Montaner has taken over as the president of the International AIDS Society (IAS) at the XVII International AIDS Conference in Mexico City. Dr. Montaner’s two-year term as IAS president will bring attention to the role of Canada, and BC specifically, at the forefront of HIV/AIDS care and research. 34 living5 BCCfE at the AIDS Conference In other news from the AIDS conference, a number of leading researchers from the BCCfE presented their results in Mexico City. Dr. David Moore and colleagues looked at what happens to people who interrupt their antiretroviral therapy for three months or more without medical supervision. Of 1,558 people who started treatment in BC between January 2000 and June 2006, 39 percent (609) went off treatment for at least three months up to June 2007. Although the reasons for treatment interruption weren’t assessed in this study, they may have had to do with lifestyle issues and access to medical care; women and IDUs were more likely to go off treatment, as were younger people and those with less advanced HIV disease. The good news is that most people (all but 2) who interrupted treatment remained alive and 74 percent eventually restarted antiretroviral therapy. Another BCCfE study presented by Dr. Natalie Jahnke looked at the complex relationship between HIV and hepatitis C (HCV) infection. Of 1,007 people who started antiretroviral therapy in the BCCfE Drug Treatment Program between August 1996 and July 2000, 574 were HCV-negative and 433 were HCV-positive, and 209 died before June 30, 2007. Injection drug users, people who were non-adherent with therapy, and those who had lower CD4 cell counts and higher HIV viral loads at the time of starting antiretrovirals had poorer rates of survival. Not surprisingly, people who were coinfected with HCV were more likely to die than those who were HCV negative; however, no difference was seen in terms of risk of death between people who had HCV genotype 1 (which is generally associated with poorer response to HCV therapy) and those infected with HCV genotypes 2 and 3. 5 Dr. Marianne Harris is a family doctor with the AIDS Research Program at St. Paul’s Hospital in Vancouver. SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 35 Cast an informed vote on October 14! In the lead-up to the federal election on October 14, it’s imperative that voters determine where the parties stand on the issue of fighting HIV/AIDS in Canada. The number of HIV-infected individuals continues to grow in our country and, while great strides have been made to curb the spread of this disease with innovative treatment programs and research, the Conservative government has continued to ignore this serious public health threat and its effective treatment. A government with appropriate policies can help prevent new cases of HIV and improve the quality of life for those who are most vulnerable to HIV, as well as for those already infected and affected by it. The Conservative government’s record of fighting this disease and supporting the ever-increasing population of those it affects is the worst of any Canadian federal government since the epidemic began. In 2004, $84 million was promised to—and budgeted for—the Federal Initiative on HIV/AIDS in Canada, yet that promise was never met and subsequent annual year budgets were slashed. Consequently, over the past two years the community-based HIV/AIDS movement in Canada has experienced a $20 million shortfall—now $11.8 million annually, a 13 percent cut—in federal government funding from what had been budgeted in 2004; that money was diverted to other programs. Ongoing antiscientific opposition to proven effective harm reduction initiatives like Vancouver’s InSite project condemns the most wretched among us to ongoing addiction, poverty, and death. Canada’s inaction in the global fight against HIV/AIDS in the last two years is an international embarrassment. We urge you to vote on October 14 and send a clear message about the leadership needed to stop HIV in Canada by voting for those parties that support an effective fight against HIV/AIDS. Important Reminder: When you vote, you MUST prove your identity and address with TWO pieces of approved ID. You have three options (visit www.elections.ca for more details): 1) Provide one original piece of identification issued by a government or government agency containing your photo, name, and address. (driver’s licence, provincial ID) 2) Provide two original pieces of identification authorized by the Chief Electoral Officer of Canada. Both pieces must contain your name, and one must also contain your address. (SIN card, credit card statement, etc.) 3) You can be vouched for by an elector whose name appears on the list of electors in the same polling division and who has an acceptable piece or pieces of identification. Both will be required to make a sworn statement. An elector cannot vouch for more than one person, and the person who has been vouched for cannot vouch for another elector. issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM 36 Page 36 living5 SeptemberqOctober 2008 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 37 SeptemberqOctober 2008 living5 37 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM where to find Page 38 help If you’re looking for help or information on HIV/AIDS, the following list is a starting point. A Loving Spoonful Dr Peter Centre Positive Living North West Suite 100 – 1300 Richards St, Vancouver, BC V6B 3G6 604.682.6325 e [email protected] www.alovingspoonful.org 1100 Comox St, Vancouver, BC V6E 1K5 t 604.608.1874 f 604.608.4259 e [email protected] www.drpetercentre.ca Box 4368 Smithers, BC V0J 2N0 3862 F Broadway, Smithers BC t 250.877.0042 or 1.886.877.0042 e [email protected] AIDS Memorial Vancouver Friends for Life Society 205 – 636 West Broadway, Vancouver BC V5Z 1G2 604.216.7031 or 1.866.626.3700 e [email protected] www.aidsmemorial.ca 1459 Barclay St, Vancouver, BC V6G 1J6 t 604.682.5992 f 604.682.3592 e [email protected] www.friendsforlife.ca AIDS Society of Kamloops Healing Our Spirit P.O. Box 1064, 437 Lansdowne St, Kamloops, BC V2C 6H2 t 250.372.7585 or 1.800.661.7541 e [email protected] 3144 Dollarton Highway, North Vancouver, BC V7H 1B3 t 604.879.8884 or 1 866.745.8884 e [email protected] www.healingourspirit.org Positive Women’s Network 614 – 1033 Davie St, Vancouver, BC V6E 1M7 t 604.692.3000 or 1.866.692.3001 e [email protected] www.pwn.bc.ca Purpose Society HIV/AIDS program 40 Begbie Street New Westminster, BC V3M 3L9 t 604.526.2522 f 604.526.6546 Red Road HIV/AIDS Network Society 804 – 100 Park Royal South, W. Vancouver, BC V7T 1A2 t 604.913.3332 or 1.800.336.9726 e [email protected] www.red-road.org AIDS Vancouver Living Positive Resource Centre Okanagan 1107 Seymour St, Vancouver BC V6B 5S8 t 604.893.2201 e [email protected] www.aidsvancouver.bc.ca Vancouver Native Health Society 101–266 Lawrence Ave., Kelowna, BC V1Y 6L3 t 250.862.2437 or 1.800.616.2437 e [email protected] www.livingpositive.ca AIDS Vancouver Island (Victoria) 1601 Blanshard St, Victoria, BC V8W 2J5 t 250.384.2366 or 1.800.665.2437 e [email protected] www.avi.org AIDS Vancouver Island (Cowichan Valley Mobile Needle Exchange) t 250.701.3667 AIDS Vancouver Island (Campbell River) t 250.830.0787 or 1.877.650.8787 AIDS Vancouver Island (Port Hardy) t 250.949.0432 AIDS Vancouver Island (Nanaimo) t 250.753.2437 AIDS Vancouver Island (Courtenay) t 250.338.7400 or 1.877.311.7400 441 East Hastings St, Vancouver, BC V6G 1B4 t 604.254.9949 e [email protected] Victoria AIDS Resource & Community Service Society McLaren Housing Society 200 – 649 Helmcken St, Vancouver, BC V6B 5R1 t 604.669.4090 f 604.669.4092 e [email protected] www.mclarenhousing.com 1284 F Gladstone Ave, Victoria, BC V8T 1G6 t 250.388.6620 f 250.388.7011 e [email protected] www.varcs.org/varcs./varcs.nsf Okanagan Aboriginal AIDS Society #330-1105 Pandora St., Victoria BC V8V 3P9 t 250.382.7927 f 250.382.3232 e [email protected] www.vpwas.com Victoria Persons With AIDS Society 101 – 266 Lawrence Ave., Kelowna, BC V1Y 6L3 t 250.862.2481 or 1.800.616.2437 e [email protected] www.oaas.ca Wings Housing Society 12 – 1041 Comox St, Vancouver, BC V6E 1K1 t 604.899.5405 f 604.899.5410 e [email protected] www.wingshousing.bc.ca ANKORS (Nelson) Outreach Prince Rupert 101 Baker St, Nelson, BC V1L 4H1 t 250.505.5506 or 1.800.421.AIDS f 250.505.5507 e [email protected] http://kics.bc.ca/~ankors/ 300 3rd Ave. West Prince Rupert, BC V8J 1L4 t 250.627.8823 f 250.624.7591 e [email protected] ANKORS (Cranbrook) 205 – 14th Ave N Cranbrook, BC V1C 3W3 250.426.3383 or 1.800.421.AIDS f 250.426.3221 e [email protected] http://kics.bc.ca/~ankors/ YouthCO AIDS Society 205 – 1104 Hornby St. , Vancouver BC V6Z 1V8 t 604.688.1441 1.877.968.8426 e [email protected] www.youthco.org Pacific AIDS Network c/o AIDS Vancouver Island (Victoria) 1601 Blanchard St., Victoria V8W 2J5 t 250.881.5663 e [email protected] Asian Society for the Intervention of AIDS (ASIA) 210 – 119 West Pender St, Vancouver, BC V6B 1S5 t 604.669.5567 f 604.669.7756 e [email protected] www.asia.bc.ca f 250.920.4221 www.pan.ca Positive Living North 1–1563 2nd Ave, Prince George, BC V2L 3B8 t 250.562.1172 f 250.562.3317 e [email protected] www.positivelivingnorth.ca BC Persons With AIDS Society 1107 Seymour St, Vancouver BC V6B 5S8 604.893.2200 or 1.800.994.2437 e [email protected] www.bcpwa.org 38 living5 For more comprehensive listings of HIV/AIDS organizations and services please visit BCPWA’s website at www.bcpwa.org and click on “Links and Services” under the “Empower Yourself” drop-down menu. SeptemberqOctober 2008 of please a.org er the nu. issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 39 Upcoming BCPWA Society Board Meetings: Date Time Location Reports to be presented October 8, 2008 1:00 Board Room Written Executive Director Report Financial Statements—July / Director of Communications October 22, 2008 1:00 Board Room Standing Committees / Director of IT November 5, 2008 1:00 Board Room Written Executive Director Report Executive Committee / Financial Statements—August November 19, 2008 1:00 Board Room Director of Support December 3, 2008 1:00 Board Room Written Executive Director Report Standing Committees / Director of HR December 17, 2008 1:00 Board Room Financial Statements—September Executive Committee / Director of Development BCPWA Society is located at 1107 Seymour St., 2nd Floor, Vancouver. For more information, contact: Alexandra Regier, office manager Direct: 604.893.2292 Email: [email protected] BCPWA Standing Committees and Subcommittees If you are a member of the BC Persons With AIDS Society, you can get involved and help make crucial decisions by joining a committee. To become a voting member on a committee, please attend three consecutive meetings. For more information on meeting dates and times, please see the contact information on the right column for the respective committee that you are interested in. Board & Volunteer Development Contact: Marc Seguin t 604.893.2298 e [email protected] Community Representation & Engagement Contact: Paul Kerston t 604.646.5309 e [email protected] Education & Communications Contact: Adam Reibin t 604.893.2209 e [email protected] Positive Gathering Committee Contact: Stephen Macdonald t 604.893.2290 e [email protected] Prevention Contact: Elgin Lim t 604.893.2225 e [email protected] Support Services Contact: Jackie Haywood t 604.893.2259 e [email protected] Treatment Information & Advocacy Contact: Adriaan de Vries t 604.893.2284 e [email protected] IT Committee Contact: Ruth Marzetti t 604.646.5328 e [email protected] living5 Magazine Contact: Jeff Rotin t 604.893.2206 e [email protected] Yes! I want to receive living5 magazine Name _________________________________________________________ Address ____________________________ City _____________________ Province/State _____ Country________________ Postal/Zip Code________ Phone ___________________ E-mail _______________________________ I have enclosed my cheque of $______ for living5 ❍ $25 within Canada ❍ $50 (Canadian $)International please send ______ subscription(s) 1107 Seymour Street ❍ BC ASOs & Healthcare providers by donation: Minimum $6 per annual subscription please send ______ subscription(s) ❍ Please send BCPWA Membership form (membership includes free subscription) ❍ Enclosed is my donation of $______ for living 5 * Annual subscription includes 6 issues Cheque payable to BCPWA w w w. b c p wa . o rg SeptemberqOctober 2008 living5 2nd Floor Vancouver BC Canada V6B 5S8 For more information visit www.bcpwa.org e-mail to [email protected] or call 604.893.2206 39 issue 56.qxd:liv poz mag.qxd 10/3/08 12:33 PM Page 40 Volunteering at BCPWA Bronwyn Punch Profile of a volunteer: Volunteer history I have been a massage therapist doing bodywork at the Loon lake retreats, and teaching the occasional workshop. Started at BCPWA I started in September 2003 and have been at every retreat since. Why pick BCPWA? I was looking for a volunteer position when I saw an ad sent to the Massage Therapists Association. I thought it was just for one retreat, but by the time I left the retreat I was really keen to come back. Everyone was so welcoming and appreciative of what I had to offer that I came away recharged. “Bronwyn’s gifted massages at the healing retreats relieve city stress, demonstrate sincere caring, and spread around a little of that Loon Lake magic dust. She is reliable, kind, and welcoming to all. She offers unique healing energy beyond the massage table—and a great sense of humour.” Rating BCPWA I have been very impressed with everyone at BCPWA and the work that they all do. Favorite memory There are so many. Playing Pictionary against Jackie ranks very high. The hugs! The other volunteers. The retreat team. The galas. Jackie Haywood, Director of Support Services Future vision of BCPWA? I hope they continue to be such a wonderful supportive team who make everyone feel welcome. Polli & Esther’s Closet Your peer-run, second time around store! Great selection! Bring your membership card and pay us a visit at 1107 Seymour Street, 2nd Floor Open Tuesday, Wednesdays & Thursdays, 11AM to 2PM for your shopping convenience 40 living5 SeptemberqOctober 2008