Dr Sean Cummings  
London, United Kingdom

Specialties: STD/STI HIV prevention

Interests: Hepatitis C, Men's Health, HIV Prevention
+44 (0) 20 7637 1600
London, United Kingdom
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HIV and Aids medication linked to dementia

Sep 27, 2010 - 0 comments

Aids medication deme

Aids medication linked to dementia

Researchers at the University of California say they have found a link between antiretroviral medication used to treat patients with HIV and brain impairments such as dementia.

Data collected from HIV negative people, HIV positive people and AIDS patients between 1990 and 1995, when antiretroviral treatment was unavailable, was compared with data from different people in the same groups collected between 2000 and 2007 when the medications were available.

The study involved around 1500 people and all were matched for age, educational level, sex, ethnicity, and neuromedical and neuropsychological evaluations.

It was found that 40% of HIV positive patients on antiretroviral treatment showed evidence of brain impairment compared with 33% of HIV positive people in the era before the medication was available.
36% of those with impairments sampled between 2000 and 2007 were just in the early stages of their infection, compared to 25% of those sampled before medication was available.

"This study underscores [the idea] that despite the benefits of modern therapies in terms of decreased mortality, there seem to be persistent neurocognitive deficits" said the University of California’s Dr. Igor Grant who led the research.

Immune system stimulation

It’s thought that the problems could be a result of chronic immune system stimulation which is induced by the treatment to achieve long-term survival.
The antiretroviral therapy means people are living longer, therefore giving the virus more time to cause problems, said Dr Grant.

Dr Victor Valcour described a “Trojan horse effect”, where white blood cells become infected with HIV, cross the blood-brain barrier and disrupt brain function.

Types of brain impairment in HIV patients

Dr Valcour estimated that as many as 50% of all HIV-infected people may have some degree of brain dysfunction, even if it is asymptomatic.  Patients from the pre- and post antiretrovirals groups showed different types of impairment.   In the groups of people infected and receiving treatment it was noted that there were more problems with memory, and in planning and decision making but fewer problems with certain types of verbal and motor skills.

Smoking and lifestyle of HIV positive people

There was also a warning from Dr. Valcour that other factors could be influencing the brain impairment. He said more attention needed to be paid to the fact that smoking, hypertension, diabetes and high cholesterol are common among HIV positive people.

Should gay men be screened for anal cancer?

Sep 26, 2010 - 0 comments

Should gay men be screened for anal cancer?

Cases of anal cancer among gay men who are HIV positive have been on the rise since the advent of antiretroviral treatment for those living with the virus.

Consequently questions are now being asked about whether men who have sex with men should be routinely screened for anal cancer using anal cytology (taking cell samples from the area) and high resolution anoscopy (a tube used to see the lining of the anus).

In an article published in Wolters Kluwer Health journal Dr Paul Fox examines the current evidence and opinion on routine anal cancer screening. Dr Fox is a Consultant Physician at the Chelsea and Westminster Hospital and at Freedomhealth Clinic London where he runs a state of the art High Resolution Anoscopy clinic.

Current UK guidelines do not recommend routine anal cancer screening and guidelines from outside the UK vary. For example in New York routine anal cytology is recommend for gay men, whereas leading groups in other states including Texas and California say that there is not yet enough research to form any guidelines.

There are a number of reasons why routine anal screening programmes have not been rolled out. The cost, both of setting up and maintaining the programme, is just one of the factors. Balancing the need for screening with any patient anxiety is another factor as well as concerns over the efficacy of screening.

The sensitivity of anal cytology is regarded as poor and so is used in conjunction with high resolution anoscopy, where medical professionals will look for the precursor lesion to anal cancer known as a high grade squamos intraepithelial lesion (HSIL).

A number of studies have been carried out to try and assess how great the risk of anal cancer is to gay men in a bid to identify groups that could benefit from routine anal cancer screening.

Dr Fox makes some criticism of the small number of studies for the way in which patients were recruited; many were not randomly selected meaning there was a potential selection bias.

However Dr Fox highlighted two recent studies which he was sure eliminated selection bias, one by randomly selecting patients and another by using the entire population of an HIV clinic.

The first study screened the 516 patients of an HIV clinic in Paris. It was found that 473 had HSIL, and that men who had sex with men were more than twice as likely to have HPV lesions -  which can be potentially cancerous - than heterosexual men or women.

A second study looked at HIV patients on antiretroviral treatment  from different demographic groups, evenly divided between MSM, heterosexual men and women. It found what Dr Fox described as “surprisingly little difference” between the groups in terms of the number of patients with HSIL. Around 5% of people in each group had an HSIL – the anal cancer precursor lesion.

The figure matched data from the days before antiretrovirals were available, leading Dr Fox to conclude that there was a possibility that the rising incidence of anal cancer in HIV-positive patients treated with anti-retroviral therapy is due to patients living longer, which gives greater rise to the cancers occurring.

Dr Fox also concluded that patients on antiretroviral treatment must therefore be at greater risk of their HSIL making a malignant transformation into anal cancer.

There were also concerns that treatment was less effective for HIV patients compared to HIV negative people. Dr Fox looked at a number of studies carried out on the treatment of HSIL and anal cancer.

A study by Goldstone et al showed that 65% of HIV positive men who received infrared coagulation treatment treatment for HSIL had new or persistent lesions after a 10 month follow-up, compared to 50% of patients who were HIV negative. A further study, which differed in its methodology by performing a repeat biopsy of the treatment site at 6 months post-treatment found only 10% of HIV positive patients were disease free.

A study on the outcome of two different types of treatment for HIV positive men with HSIL has provisionally shown little difference. It looked at patients who were given a single infrared coagulation treatment and those who applied trichloroacetic acid once monthly for four months. There was an individual clearance of 68% with individual lesions with IRC and 87% in the group treated with trichloroacetic acid.

A further study involved a placebo controlled study of 53 HIV patients using a self-applied imiquimod cream. In the patients using the cream the response rate was 39% compared to those using the placebo cream.

In a further study where participants were offered open-label imiquimod the response rate was 40% with half of those patients having a complete and sustained resolution of their lesions.

It was noted that the benefit of these treatments is that the lesions disappear and although some recur in different locations it is thought that lesions that have not been static for some years will carry only a low risk of malignant transformation.
According to the article it is therefore reasonable to suppose that treatment of HSIL will reduce the likelihood of anal cancer, but this has not yet been proven.

Dr Fox also concluded that anal cytology is a validated means of detecting anal cancer but is best restricted to selected patients.

He recommends that clinics carry out physical, digital examination of the anus to look for abnormalities and that this becomes the standard at HIV clinics.

A study in San Francisco highlights the important of digital examination. The cases of 21 patients who had developed anal cancer were examined and it was found that 19 had presented with palpable mass, an induration or ulcer. The implication was that physical examination could have picked up these lesions at an early stage.

Patients should also be encouraged to self-examine with Dr Fox saying it may be “just as effective as a cytology based approach”.

He says the clinics must play an important role in encouraging patients to self-examine and helping them learn how to carry it out properly. The report suggests clinicians carry out the initial examination to prevent patients becoming concerned by lumps that are either benign or part of their normal anatomy.

HIV warning for over 50s

Sep 22, 2010 - 0 comments

HIV warning for over 50s

More over 50s are contracting HIV than ever before and there is a warning that their diagnoses could come too late.

710 over 50s were diagnosed with HIV in 2007, compared to 299 in 2000, according to new figures released by the Health Protection Agency (HPA).

Other sexually transmitted infections have shown a similar increase in the same age group, rising at a faster rate than in younger age groups.

Late HIV diagnosis

Almost half of those diagnosed in 2007 were found to be at an advanced stage of HIV infection, severely limiting the benefits of HIV treatment.

In fact 14% of those diagnosed at an advanced stage in their infections were dead a year later, compared to 1% of older patients who had been diagnosed earlier.

“We have a group of people who don’t get tested because they don’t think they are at risk,” said Dr Valerie Delpech of the Health Protection Agency.

The HPA estimates that half of those diagnosed between 2000 and 2007 were actually infected when they were aged 50 or over.

Older people with HIV were more likely to be gay, white men. But “it wasn’t all gay men”, said Dr Delpech, “In fact, there were a large proportion of heterosexual men and women”.

The charity Terrence Higgins Trust says its own research confirms that over 50s were now the fastest growing group of people with HIV in the UK.

Better sex for older people

Some experts say more divorces and better health might be behind the rise in HIV infection rates, with older people having more sex.

“What this means is that screening is particularly important in people over 50,” said Dr. Anupam B. Jena, who was not involved in this study. “The take home point from this paper is that it always makes sense to be screening younger people for HIV, but that maybe the balance should shift a little bit toward older people.”

A separate study carried out by Dr. Jena found that 60-year-old men taking Viagra had twice the rate of STDs of those not taking the drug.

HIV ‘out of control’ among French gay men

Sep 21, 2010 - 0 comments

HIV ‘out of control’ among French gay men

Doctors in France have described HIV among gay men in France as “out of control” after a study into the latest HIV infection rates.

Scientists from the French National Institute for Public Health found that while new cases of HIV had dropped dramatically in the general population, there was no drop in cases among gay men. Their findings were published in the September 9 Lancet Infectious Diseases journal.

In 2003 8,930 new infections were diagnosed but in 2008 that number had reduced to 6,940.

Almost half (48%) of the 6,940 new cases in 2008 were among gay men, with the scientists concluding that the incidence of HIV among gay men is 200 times higher than in the general population. Non-French nationals made up 23% of all infections in 2008, with most of them thought to be from sub-Saharan Africa. HIV infection among injecting drug users, despite rising in other countries, stayed low between 2003 and 2008 at around 1 or 2 percent.

“Our results provide a new perspective on the HIV epidemic in France,” said Dr Stephane Le Vu, “HIV transmission disproportionately affects certain risk groups and seems to be out of control in the MSM (men who have sex with men) population.”

The study has prompted experts to warn that new HIV prevention strategies are needed and must be targeted at the groups most at risk. There is also a warning that the French figures reflect similar rates of HIV infection among gay men worldwide, which Dr Robert Hoff from the British Colombia Centre for Excellence in HIV/AIDS described as “unacceptably high” and added his voice to calls for new prevention strategies.

“This approach should include targeted structural interventions directed at specific populations, behavioural interventions directed at individuals, and new biomedical interventions, including expanded coverage of anti-retroviral therapy to all HIV infected individuals who meet eligibility criteria for treatment,” said Dr Hoff.