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SUMMER 2007
News and Literature Reviews
New Study Demonstrates Entecavir's Activity in Inhibiting Replication of HIVI-1, Raises Concerns Regarding Resistance to Anti-HIV-1 Drugs A new study found evidence that contradicts previous findings that entecavir does not inhibit replication of HIV-1 in clinically relevant doses. The study, conducted by researchers at the Johns Hopkins University School of Medicine and the Howard Hughes Medical Institute, found that the drug, which is used to treat chronic hepatitis B virus infection (HBV), does indeed lead to 1-log10 decreases in HIV-1 RNA when administered in clinically relevant doses. These findings were based on a case study of three HIV and HBV-infected patients and included both an in vitro and in vivo analysis of the drug's effects. Entecavir had previously been recommended for use in HIV-1 and HBV coinfected individuals who required treatment for HBV, but not HIV-1, as it was not believed to inhibit replication of HIV-1 or pose any threat of causing anti-HIV drug resistance in patients. Researchers, however, also found that entecavir could select the M1847 mutation and thereby confer a high level of resistance to the antiretroviral (ARV) drugs lamivudine and emtricitabine in some patients. This discovery suggests that previous recommendations on the use of entecavir in persons who are not being treated for HIV-1 should be reconsidered in order to prevent resistance to anti-HIV-1 treatment options. In an editorial on this topic, Dr. Martin Hirsch explained that the difference in findings between the two studies on entecavir as a replication inhibitor for HIV-1 could be the result of a difference in the sensitivity of the assays, virus strains, or amount of virus used in each of the two studies. In addition, Dr. Hirsch stated that guidelines for entecavir's use are now being reconsidered. The company that manufacturers the drug has issued a letter to health care providers to reiterate that the drug had not been evaluated in coinfected patients who were not simultaneously receiving HIV-1 treatment. Also, the Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents no longer recommends entecavir for coinfected patients who are not also receiving anti-HIV-1 treatment. The HBV Drug Entecavir --- Effects on HIV-1 Replication and Resistance. McMahon M. et al. New England Journal of Medicine. 2007;356:2614-21. Entecavir Surprise. Hirsch, Martin S. New England Journal of Medicine. 2007;356:2641-43. Young Incarcerated Men's Perceptions of and Experiences with HIV Testing An analysis of the formative research phase of Project START (STD and AIDS Risk Reduction Trials) reveals former incarcerated men's experiences with and opinions of HIV testing, both inside and outside the correctional setting. Project START, which is funded by the CDC, conducted both qualitative and quantitative face-to-face interviews with 105 men at 5 separate time-intervals-before each prisoner's release and 1 week, 1 month, 3 months, and 6 months after release. The interviews revealed that, while nearly all of the men had been tested for HIV and most had been tested on multiple occasions, the men had fairly consistent themes in discussing their reasons for getting tested, as well as the barriers that they encountered. Most men cited their perceptions of testing being mandatory, convenient, or free as factors in getting tested for HIV in prison. Conversely, the men consistently reported lack of health insurance, employment, and time as barriers to testing outside of prison. Also, many men stated that they only sought health care in emergency situations and it did not occur to them to get tested for HIV or even consider their risk factors. Other men reported that they knew that they were at risk for HIV, but feared knowing their HIV-status. The study also discussed the prevalent perception that "no news is good news," revealing that most men believed themselves to be HIV-negative if they did not receive their test results. Only half of the men reported receiving test results and most men did not receive posttest counseling. These findings emphasize the need to strengthen test result notification and counseling guidelines, as inadequate procedures can lead to missed opportunities for prevention and risk-reduction counseling. Young Incarcerated Men's Perceptions of and Experiences with HIV Testing. Kacanek, D. et al. American Journal of Public Health. 2007;97(7):1-7. Release from Prison - A High Risk of Death for Former Inmates Researchers from the Puget Sound Veterans Affairs Medical Center recently published a retrospective cohort study comparing the risk of death between all inmates released from the Washington State Department of Corrections between July 1999 and December 2003 and the rest of Washington State's residents. The study, which was published in the New England Journal of Medicine, obtained data on the Washington State residents from the Wide-ranging OnLine Data for Epidemiologic Research system of the Centers for Disease Control and Prevention. All data was analyzed using indirect standardization and was adjusted for age, sex, and race, so as to prevent the influence of confounding variables on the study's evaluation. Former inmates were found to have an adjusted risk of death that was 3.5 times higher than that of the state's general populous. In addition, the study revealed that former inmates were at a shocking 12.7 times higher adjusted risk of death during the first two weeks after their release from prison than other Washington State residents. The leading causes of death for former inmates were drug overdose, cardiovascular disease, homicide, and suicide. Many of the deaths linked to drug overdose involved cocaine, methamphetamine, heroin, and methadone, while firearms were involved in many of the suicides and homicides. The excess risk of suicide could be attributable to the prevalence of mental illness in inmates, in combination with the stress of reentry and possible lack of access to mental health care. Researchers suggest that factors such as level of education, employment status, level of income, neighborhood of residence, and health insurance status could account for some of the disparity between former inmates and other state residents, although it is unlikely that socioeconomic status could account for all of the variation. This study underscores the need for increased planning for the transition from prison to the community, which could include intensive case management during the period immediately following release in order to ensure that inmates have proper access to medical and mental health care. Relase from Prison --- A High Risk of Death for Former Inmates. Binswanger, I. Et al. New England Journal of Medicine. 2007;356:157-65. Compiled by Christine Devore, IDCR Intern
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