HIV This Week

Cameron E, Burris S, Clayton M. HIV is a virus, not a crime: ten reasons against criminal statutes and criminal prosecutions. J Int AIDS Soc. 2008;11(1):7. [Epub ahead of print]

The widespread phenomenon of enacting HIV-specific laws to criminally punish transmission of, exposure to, or non-disclosure of HIV, is counter-active to good public health conceptions and repugnant to elementary human rights principles. The authors provide ten reasons why criminal laws and criminal prosecutions are bad strategy in the epidemic.

Editors’ note: HIV is a virus not a crime and criminalisation of HIV is hostile to both HIV prevention and treatment. Knowing one’s HIV status and setting out deliberately to infect another person and achieving this aim demonstrates criminal intent warranting prosecution. However, there is no public health justification for invoking criminal law sanctions against those who unknowingly and unintentionally transmit HIV or expose others to it. Such criminalisation discourages HIV testing and counselling, the pathway to treatment access and HIV status-specific prevention; reinforces stigma, enhances fear, and isolates people living with HIV; and undercuts efforts to address the epidemic.

Hütter G, Nowak D, Mossner M, Ganepola S, Müssig A, Allers K, Schneider T, Hofmann J, Kücherer C, Blau O, Blau IW, Hofmann WK, Thiel E. Long-term control of HIV by CCR5 Delta32/Delta32 stem-cell transplantation. N Engl J Med. 2009;360(7):692-8.

Infection with the human immunodeficiency virus type 1 (HIV-1) requires the presence of a CD4 receptor and a chemokine receptor, principally chemokine receptor 5 (CCR5). Homozygosity for a 32-bp deletion in the CCR5 allele provides resistance against HIV-1 acquisition. Hütter and colleagues transplanted stem cells from a donor who was homozygous for CCR5 delta32 in a patient with acute myeloid leukemia and HIV-1 infection. The patient remained without viral rebound 20 months after transplantation and discontinuation of antiretroviral therapy. This outcome demonstrates the critical role CCR5 plays in maintaining HIV-1 infection.

Editors’ note: After 20 months, this patient’s CD4+ counts are in the normal range; HIV-1 is not detectable in blood, bone marrow, or rectal mucosa; and the disappearance of the effector T-cells that normally fight HIV suggests that HIV is not around to provoke them. The patient could still be harbouring a CXCR4 type of HIV; many people die from bone marrow transplantation procedures, and people lacking CCR5 may be more susceptible to serious effects from certain infections. Nonetheless, this case will continue to be followed with interest and will no doubt open the door to further innovations in HIV treatment.

Behringer RR, Gonzalez G, Shpall EJ, Gathe J. Cord blood stem cell therapy for acquired immune deficiency syndrome. Stem Cells Dev. 2008. [Epub ahead of print]

Cord blood stem cell transplantation is routinely used to treat hematopoietic diseases. Individuals who are homozygous for the Delta32 polymorphism of the CCR5 locus, encoding a co-receptor for HIV-1, are normal and resistant to HIV infection. Here Behringer and colleagues suggest that public cord blood repositories are likely to contain CCR5 homozygous units that could be used as a therapy for HIV infected individuals.

Editors’ note: Cord blood stem cells, collected non-invasively from the placenta and umbilical cord after separation from a newborn, are less mature and would require less matching between donor and recipient than is the case for a bone marrow transplant. Homozygosity of the CCR5 delta 32 allele (meaning both chromosomes have the same 32 base pair deletion) occurs in 1 to 3% of current cord bank specimens in western populations that have high allele frequencies. The idea of cord stem cells for HIV treatment has yet to be explored but may have some merit.

Klitzman R. Views of the process and content of ethical reviews of HIV vaccine trials among members of US Institutional Review Boards and South African Research Ethics Committees. Dev World Bioeth. 2008;8(3):207-18.

Given the ethical controversies concerning HIV vaccine trials, Klitzman aimed to understand through an exploratory study how members of institutional review boards in the United States and research ethics committees in South Africa view issues concerning the process and content of reviews of these studies. The author mailed packets of 20 questionnaires to 12 United States institutional review board chairs and administrators and seven research ethics committee chairs to distribute to their members. Klitzman received 113 questionnaires (76 from the United States and 37 from South Africa). In both countries, members tended to be white males with advanced academic degrees. Compared to the United States, South African members called for ‘major changes’ in HIV vaccine trial protocols more frequently (p = 0.004), and were less likely to think that HIV vaccine trial participants understood risks and benefits (p = 0.033) or informed consent forms (p = 0.000). In both countries, members were divided on several critical issues (e.g. the minimum standard for treatment for HIV vaccine trial participants who became infected during the HIV vaccine trial), but agreed that they needed more training. Of the South African respondents, 40% reported that they were ‘self-taught’ in ethics. This study, the first we know of to offer quantitative data comparing US vs. non-US institutional review boards/research ethics committees, thus suggests key similarities and differences (e.g. compared to South African respondents, United States respondents appeared to overestimate participants’ understanding of informed consent), along with needs for education. These initial exploratory data in this area have important implications for institutional review boards, research ethics committees, policy-makers and scholars concerning future practice, training, policy, and investigations in research ethics, and prevention and treatment of HIV and other diseases in the developing world and elsewhere.

Editors’ note: This study did not take into account the 2007 UNAIDS/WHO Ethical considerations in biomedical HIV prevention trials document which contains explicit guidance on treatment for trial participants who acquire HIV infection during the course of a trial. Nonetheless, the comparative findings reported here suggest that lack of ethnic diversity in committee membership is a problem for institutional review boards/ethics committees in both the South African and US contexts. South African research ethics committee members may have had more field experience – they had better awareness of how trial participants might or might not comprehend key issues. This supports the idea that local institutional review boards/ethics committees are best placed to assess whether procedures and practices are likely to ensure that consent is truly informed.

Roura M, Urassa M, Busza J, Mbata D, Wringe A, Zaba B. Scaling up stigma? The effects of antiretroviral roll-out on stigma and HIV testing. Early evidence from rural Tanzania. Sex Transm Infect. 2008. [Epub ahead of print]

This study aimed to investigate the interplay between antiretroviral therapy scale-up, different types of stigma, and voluntary counselling and testing uptake two years after the introduction of free antiretroviral therapy in a rural ward of Tanzania. Qualitative study using in-depth interviews and group activities with a purposive sample of 91 community leaders, 77 antiretroviral therapy clients and 16 health providers. Data were analysed for recurrent themes using NVIVO-7 software. The complex interplay between antiretroviral therapy, stigma, and voluntary counselling and testing in this setting is characterised by two powerful but opposing dynamics. The availability of effective treatment has transformed HIV into a manageable condition which is contributing to a reduction of self-stigma and is stimulating uptake of voluntary counselling and testing. However, this is counter-balanced by the persistence of blaming attitudes and emergence of new sources of stigma associated with antiretroviral therapy provision. The general perception among community leaders was that as antiretroviral therapy users regained health they increasingly engaged in sexual relations and «spread the disease». Fears were exacerbated because they were perceived to be very mobile and difficult to identify physically. Some leaders suggested giving antiretroviral therapy recipients drugs «for impotence», marking them «with a sign», and putting them «in isolation camps». In this context, traditional beliefs about disease aetiology provided a less stigmatised explanation for HIV symptoms contributing to a situation of collective denial. Where anticipated stigma prevails, provision of antiretroviral drugs alone is unlikely to have sufficient impact on voluntary counselling and testing uptake. Achieving widespread public health benefits of antiretroviral therapy roll-out requires community-level interventions to ensure local acceptability of antiretroviral drugs.

Editors’ note: Stigma may be internalized (self-stigma), anticipated (stigma people expect from others), secondary (affecting those related to the infected person) or enacted stigma (discrimination). Stigma related to inability of ill people living with HIV to conduct productive activities and care for themselves (‘drain of resources’) may be reduced by the health enhancing effects of antiretroviral treatment as people regain weight and energy. However, without social analysis, community engagement, and careful planning, scaling up antiretroviral treatment can lead to new sources of treatment-associated stigma that ostracizes people on treatment and dissuades others from learning their HIV serostatus.