Happy New year

May new year bring lots of smiles on all PLHA all over the world
Bharti and Saini

Surveillance Case Definitions for HIV Infection and AIDS Revised

Surveillance Case Definitions for HIV Infection and AIDS Revised

Laurie Barclay, MD
Medscape Medical News 2008. © 2008 Medscape
December 10, 2008 — Surveillance case definitions have been revised for HIV infection in adults, adolescents, and children younger than 18 months of age and for HIV infection and AIDS in children aged 18 months to younger than 13 years, according to a report published in the December 5 issue of the Morbidity & Mortality Weekly Report. These case definitions are intended for public health surveillance only and not as a guide for clinical diagnosis.

"Since the beginning of the [HIV] epidemic, case definitions for HIV infection and [AIDS] have undergone several revisions to respond to diagnostic and therapeutic advances and to improve standardization and comparability of surveillance data regarding persons at all stages of HIV disease," write Eileen Schneider, MD, and colleagues from the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. "HIV testing is now widely available, and diagnostic testing has continued to improve; these changes are reflected in the 2008 revised case definition for HIV infection, which now requires laboratory-confirmed evidence of HIV infection to meet the case definition among adults, adolescents, and children aged 18 months to <13 years."

Specific revisions are as follows:

For adults and adolescents aged older than 13 years, the HIV infection and AIDS classification system and surveillance case definitions have been revised and combined into a single case definition for HIV infection.
The surveillance case definition in this group requires laboratory-confirmed evidence of HIV infection. The stage of infection is determined from the lowest CD4+ T-lymphocyte count (or concordant CD4+ T-lymphocyte percentage of total lymphocytes) or from the presence of AIDS-defining conditions.
When the CD4+ T-lymphocyte count and the CD4+ T-lymphocyte percentage do not correspond to the same severity stage, the case should be classified as the more severe stage.
Acute HIV infection, which occurs approximately during the time from viral acquisition until seroconversion, is diagnosed from documented, detectable HIV RNA or DNA or p24 antigen in plasma or serum when HIV antibody test on the same day is negative or indeterminate.
Laboratory criteria for HIV infection are:

A positive result from an HIV antibody screening test (eg, reactive enzyme immunoassay) confirmed by a positive result from a supplemental HIV antibody test (eg, Western blot or indirect immunofluorescence assay); or
A positive result or report of a detectable quantity from any of the following HIV virologic tests: HIV DNA or RNA detection test (eg, polymerase chain reaction); HIV p24 antigen test, including neutralization assay; or HIV isolation (viral culture).
Case classification for HIV infection stages is as follows:

Stage 1: No AIDS-defining condition, and either CD4+ T-lymphocyte count greater than 500 cells/μL or CD4+ T-lymphocyte percentage of total lymphocytes higher than 29%.
Stage 2: No AIDS-defining condition and either CD4+ T-lymphocyte count of 200 to 499 cells/μL or CD4+ T-lymphocyte percentage of total lymphocytes of 14% to 28%.
Stage 3 (AIDS): Laboratory confirmation of HIV infection and CD4+ T-lymphocyte count of more than 200 cells/μL or CD4+ T-lymphocyte percentage of more than 14%, or documentation of an AIDS-defining condition (with laboratory confirmation of HIV infection).
Stage unknown: Laboratory confirmation of HIV infection and absent data on CD4+ T-lymphocyte count or percentage and absent information on presence of AIDS-defining conditions.
For children younger than 13 years, the HIV infection case definition has been revised.

For children younger than 18 months, the HIV infection case definition replaces the definition published in 1999 and applies to all HIV variants. It takes into account newly available testing technologies.

Laboratory criteria for children younger than 18 months have been revised for the category of presumptively uninfected with HIV, but no significant changes have been made to the other 3 categories (definitively HIV infected, presumptively HIV infected, and definitively uninfected with HIV).

For surveillance purposes, a child younger than 18 months who is born to an HIV-infected mother is categorized as presumptively uninfected with HIV if the criteria for definitively uninfected with HIV are not met, if there is no other laboratory or clinical evidence of HIV infection, and if at least 1 of the following laboratory criteria are met:

2 negative RNA or DNA virologic tests, from separate specimens, both of which were obtained at age older than 2 weeks and 1 of which was obtained at age older than 4 weeks; or
1 negative RNA or a DNA virologic test from a specimen obtained at age older than 8 weeks; or
1 negative HIV antibody test from a specimen obtained at age older than 6 months; or
1 positive HIV virologic test followed by 2 or more negative tests from separate specimens, 1 of which is a virologic test from a specimen obtained at age older than 8 weeks or an HIV antibody test from a specimen obtained at age older than 6 months.
For children aged 18 months to younger than 13 years, laboratory-confirmed evidence of HIV infection is now required to meet the surveillance case definition for HIV infection. Without such evidence, diagnostic confirmation of an AIDS-defining condition alone is no longer sufficient to classify a child as HIV infected for surveillance purposes.

For children aged 18 months to younger than 13 years, the AIDS case definition has been revised and now requires laboratory-confirmed evidence of HIV infection.
For children younger than 18 months, there have been no changes to the AIDS case definition.
For children younger than 13 years, there have been no changes to the HIV infection classification system or to the 24 AIDS-defining conditions.
"Public health surveillance data are used primarily for monitoring the HIV epidemic and for planning on a population level, not for making clinical decisions for individual patients," the authors write. "[The Centers for Disease Control and Prevention] and the Council of State and Territorial Epidemiologists recommend that all states and territories conduct case surveillance of HIV infection and AIDS using the 2008 surveillance case definitions, effective immediately."

Morb Mortal Wkly Rep. 2008;57(RR10);1—8.

world AIDS DAY,2008

world AIDS Day,2008

World AIDS Day-2008-AAG on Meow 104.8 FM

Friends ,
please also look out or hear me Rakesh Bharti in Amritsar on the topic How can women be involved in spreading awareness.It will be a live conversation and will include the role of some HIV positive women in Amritsar in tackling the menace called AIDS.The timings are between 10 to 11 AM
Ravi Saini ,another activist from Amritsar will be there too between 8 to 9 AM.
Both of shall look forward to any further querries and commnents.
Dr.Rakesh Bharti,
BDC Research Center,
Clinical wing of AIDS Awareness Group,Amritsar
27-D,Sant Avenue,The Mall,Amritsar.
143001
email-rakeshbharti1@rediffmail.com

AIDS Awareness thru Rail

Your querries -Our answers-treating HIV 2

Dear Friends,
I am posting one comment with one example,just to initiate a forum for quenching the thirst of knowledge.

How do we manage HIV-2 patient

I came across a patient from a neighbouring city of Jalandhar,where a young strongly built and nourished man is having HIV2 for many years(4-5) now.
He has been visiting various medical and specilist who see some HIV patients from timew to time. He has carried out viral load test and cd4 n number of times and has varying results ranging from few hundred to thousand Viral copies and 400 to 700 Cd4.
The doctors started treating him because of fall in cd4 with combination of drugs(NRTI and NNRTI's).
The catch here is that no lab detects or does a viral load of HIV 2;the catch is cd4 cna vary in variuos conditions (if you have fever;if you are in bad mood etc) or even has diurnal variations;the catch is Efaviranez and Nevirapine are not at all effective for HIV2.
Lessons-----
if at all one wants to monitor and treat HIV 2-there are no clear guidelines but clinical parameters are the best and to treat please do not use NNRTI,use PI plus nuke backbone.
Open for discussion.
Bharti

Self-Evaluation

A Reflection

Landing at the Amritsar International Airport, I stepped off the airplane with a building sense of exhilaration. The bustling city of Amritsar … this was where I was going to spend the next month or so. Having exited the airport, the first thing that struck me was the extreme heat; nevertheless, I was very excited to be there!

Three days later, I contacted and met with Dr. Dinesh Kumar Sharma who was my primary contact. For the next four hours, I was briefed with the nuances of the Indian health care system, and with a general overview of the HIV+/AIDS situation in India. We then went to meet with Dr. Rakesh Bharti, an HIV specialist as designated by the American Academy of HIV/AIDS. He was the doctor I was going to be working with for the next month, as he was in close contact with the HIV+ population of Amritsar, India.

After the first introductions, it was mutually determined that I would attend Dr. Bharti’s clinic every morning for five hours, and some evenings. Because Dr. Bharti is a dermatologist, not all patients who enter his clinic are HIV+; in fact, most are not. Despite that, sitting in Dr. Bharti’s clinic while he was attending to patients who were HIV-, was also a great learning experience! It was very enlightening to observe Dr. Bharti’s interactions with his patients.

The doctor-patient relationship in India is significantly different from how it is in Canada. From my personal experiences, most doctors in Canada are polite and firm. There is no perception of emotion in the way they conduct their duties. They know and perform their duties well, but are often cold. Patients here are thankful to doctors for their services, and respect doctors just as they would respect any other person. The situation is very different in India. It should be noted that I am mainly basing my conclusions on watching Dr. Bharti’s interactions with his patients. Another source I am using is the charity hospital where I once went to observe HIV+ patients. Dr. Bharti serves mainly the affluent strata of Amritsar’s society who come with dermatological complications, while offering free counseling to needy HIV+ patients. Dr. Bharti also procures ART from drug stores at a cheaper rate and sells them to his patients without making any profit. On the other hand, the charity hospital serves only the socioeconomically less fortunate. Dr. Bharti was firm and polite with his patients. For the most part, patients followed and respected his suggestions with reverence. There were however, a few patients who indicated their disagreement to Dr. Bharti’s suggestions. While Dr. Bharti still treated them well, it seemed to me that patients did not usually contradict their doctors in India. It was pleasing to note that Dr. Bharti did not differentiate between the HIV+ patients who he was counseling for free with his other patients, in terms of care. He was attentive to both. Another positive attribute of the doctor-patient relationship I noted in Dr. Bharti’s clinic was the emotion Dr. Bharti displayed for his patients. He showed his patients (particularly the HIV+ patients) that he really was trying to procure the best care he could for them. He listened to their queries and concerns without rushing them, and was always ready to offer his suggestions. He counseled them on a multitude of issues, even those unrelated to their disease status. All this was done without showing obvious sympathy for the patients, which in my opinion, was the best thing Dr. Bharti could have done! It was obvious that the patients were very thankful to Dr. Bharti not only for the medical assistance they received from him, but also for his kindness to them.

Things were once again different in the charity clinic. The doctors there were dismissive of their patients in general. They were not rude, but something in their tone suggested that they felt superior to their patients. When I visited, the doctor attending to me was not attentive of the patients who were waiting to see him. Despite my repeated suggestions that he should attend to his patients because they needed to see him more urgently, he insisted on waiting with me until my ride arrived. After about 10 minutes or so, I pretended that I saw my ride and left so that the patients could get the care that they required. On a positive note however, I noted that within this hospital, there was not much of a difference in the manner in which the doctors and nurses treated HIV+ patients when compared with patients who did not have this disease. Unfortunately however, from my communication with other patients, I knew that this was not the case in most other hospitals. Comparing and contrasting the doctor-patient relationships in Canada and India, I feel that neither is perfect. Both have their strengths and weaknesses, and each should learn from the other.

For the first week or so, I only observed the HIV+ patients who visited Dr. Bharti. At this point, I did not conduct any interviews because it was important for me to first understand the patients themselves. I did not want to inadvertently hurt any patient’s sensitivities, due to the cultural differences present between India and Canada. I observed patients from all walks of life, and in varying stages of their disease. Some were newly diagnosed, while others were at the end stages of their lives. Patient demographics were very varied – some were widows of HIV+ husbands while others were newlyweds; yet others were toddlers wondering why their families did not love them as much as they did their siblings.

I noted two glaring and startling trends within my first week in Dr. Bharti’s clinic: first, a vast majority of the population was mistrustful of the government, and second, very few people were willing to be videotaped. The government of India has recognized the threat HIV/AIDS is posing in India and has begun to offer free ART to the needy. It is therefore startling to note that although the vast majority of the patients who visit Dr. Bharti are unable to afford the treatment, they are still reluctant to go to the government clinics. This confused me until I met with an HIV+ truck driver who told me that the reason he did not want to go to the government clinic is because of his fear of being killed by them! While the government does not actually euthanize HIV+ patients, it was an eye-opener for me to note that HIV+ patients were discriminated against so blatantly that they felt it was very likely that they would be murdered for their disease! According to Dr. Bharti, this feeling is shared by many other HIV+ patients. I soon realized that the reluctance most of the patients felt in being videotaped was due to the fear that someone they know would find out about their disease and spread the word, after which the entire society would shun them. I admit here that were it not for the trust the patients had for Dr. Bharti, I would have never been able to videotape a single patient. I should also mention that the patients were clearly told that being videotaped was entirely voluntary and that they would receive no boon for agreeing and suffer no consequences for refusing.

For the next two weeks, I interviewed, videotaped and audio-recorded the stories of many patients. Due to a technical glitch, I lost the audio-recordings from two patients. Nevertheless, each patient I interviewed had something new to tell me. One thing however, was common in all their stories – the discrimination they faced. Sometimes it was blatant, and sometimes it was subtle. Sometimes they were ashamed to admit it, although ultimately, it wasn’t difficult to identify when this was the case.

I will now briefly describe three patients that I met during this time, who were reluctant to be videotaped. I chose these three patients because I was moved by their circumstances and also because I believe from my experiences, that their conditions were very typical of most of the HIV+ patients in Amritsar, India.

A widowed young lady of about 27 years of age came in one morning. She came with a 5 year-old girl who was coughing incessantly and looked like she was only 3 years old. No other adult accompanied her. She had been infected by her husband who had already succumbed to the vicious effects of AIDS, and had died. She was still living with her in-laws but was not treated well. Her utensils, including her plates and glasses were separated. She lived in an isolated corner of the house with her young daughter who was also HIV+. I soon found out that she had twin daughters, one of whom was HIV+ and the other who was healthy. She was not allowed to spend any time with her healthy daughter, or to be in close proximity with her. Any food that she cooked was not eaten by the rest of the family; only her and her infected daughter. She was not financially stable, and therefore, could not afford to pay for medications for her daughter, although her in-laws were paying for her to take the medications. All her hopes had been dashed; at the age of 27, she was desolate. Her young daughter on the other hand, does not understand anything yet; all she knows is that she is not loved like her twin is by her family members.

I met another middle-aged man who seemed tired of life in general. He asked me if there were any medications in Canada, whereby after one application, he would be free of the disease. Regretfully, I had to tell him that such a medication had not yet been developed anywhere in the world, although research was ongoing. Then I was faced with the most difficult question I have ever answered: he asked me how long he was going to live. Nothing in the world could have prepared me for that question. I did not let him perceive my internal conflict however, as this would only have served to increase the frustration he had with his disease. Instead, I told him that as long as he maintained a balanced diet and continued to take his medications, he could hope to lead a normal life, as long as any other person. Was this a lie? I don’t know, but there was no other way to answer his question.

My entire duration in India was filled with experiences that taught me something new every day. I learnt about a culture which is mine, and yet alien. I learnt about the doctor-patient relationships that exist half way across the world. I learnt about the biological background of HIV/AIDS. I learnt about the social stigma accompanying this disease, through firsthand experience and through the published literature. It is also incredible how much I learnt about myself as a person.

The question of an evaluation based on a grade is always a difficult one. Nevertheless, after reflecting on what I personally expected to have learnt at the end of the project and comparing it with what I actually learnt, as well as how I have grown as a person, I believe that I deserve a good grade.

This is based on many things. Firstly, I have never received any formal or informal training whatsoever in video editing. My desire to be able to convey my feelings and learning in a method different from writing it down contributed to me taking the risk and learning everything from scratch. I learnt how to operate the program from the manuals provided with the video editing program. I learnt the basics of shooting a video from various forums dedicated to documentary-making on the internet; this included lighting, audio, and a multitude of other things that I had to take into consideration. I watched many unprofessionally-made documentaries in order to gain an appreciation for what a good documentary is.

In addition to this, I communicated with the HIV+ patients in the Punjabi language, despite the fact that I am not very proficient in the language. While Punjabi is my mother tongue, there is a great difference between communicating simple everyday greetings and communicating with village-dwellers who speak no other language. I was not born in India, and had not visited it since 1999, and thus, my command of the Punjabi language is passable at best. Regardless of that, my wish to speak with the patients themselves to be able to gain a better appreciation for their experiences made me work extra hard to learn the language well enough to be able to communicate with them. I also translated everything said by the patients into the English language in order to be able to write the subtitles for my documentary. I received no external help in doing so. Indeed, I’ve received numerous compliments after my return back to Canada on the incredible improvement I have made in my command of the Punjabi language!

Thirdly, I made the most of the resources I had. The internet connection in Amritsar, India was painfully slow. I tried three different internet cafes, but to no avail. This made researching for literature very difficult. Getting on the McMaster library homepage would take two minutes, and the search took even longer. After looking through the first page of the search results, it would take another two minutes before the next page would load. To get to a page in order to read the abstract of a paper took me a long time as well. Regardless of these difficulties, I managed to complete writing my paper; this was a great accomplishment in and of itself. I will admit however that I was not able to write my report as well as I would have liked to, due to the temporal and internet constraints that were present. Personally, I believe that I have too few references. However, since I was writing on topics that were accepted and not debated, this was not a very big detriment. Overall, I was pleased with the effort that I had put into writing my paper. In addition, I visited a charity hospital alone in order to better understand the full spectrum of the patient population who had this disease as well as the care that they received. I opted not to take someone else with me, because I was aware that the patients would be more suspicious of two people questioning them as opposed to one. I also tried to be as polite as possible, while trying to get my questions across in Punjabi. While there, I spoke to two HIV+ patients: one of them had active T.B. and was in the armed forces, while the other was a widowed wife of an HIV+ patient. From them, I learned about how they were treated by all levels of society; from their families to the hospital personnel. While there, I also interviewed a doctor about his views on the discrimination faced by HIV+ patients in India.

Lastly, I believe that it is very important to mention that my supervisor, Dr. Bharti, was very pleased with what I had managed to accomplish. In the final interview, he told me himself that he was happy with my work. He then mentioned that he tried to be strict while grading me, as he was aware that overly-inflated grades would cause the BHSc. program to be mistrustful of the quality of what I had learned. Also, although he did not specify the exact problem, Dr. Bharti mentioned that he had had negative experiences in the past with other foreign students. He then said that after the project that I had completed, he was now very receptive towards receiving foreign students to learn under his tutelage.

Overall, I am very thankful to have gotten the opportunity to have learnt so much this summer. I believe that I completed the project to the best of my ability, often surpassing the goals that I had set for myself. I would recommend such a learning experience to anybody and everybody.