But that development, as welcome as it is, should not distract us from the need for an HIV vaccine, says Dr. Mark J. Mulligan, a professor of medicine at Emory University, in a new GHN Commentary.

“Every year for 15 years, approximately 56,000 Americans have become newly HIV-infected,’’ writes Mulligan. “This number has not fallen despite behavioral education efforts.’’

Friday is HIV Vaccine Awareness Day, and this weekend, Action Cycling Atlanta puts on the AIDS Vaccine 200 Bike Ride.

Here’s a link to Mulligan’s Commentary.

Georgia Health News welcomes Commentary submissions. If you would like to propose a Commentary piece for Georgia Health News, please email Andy Miller, editor of GHN, at amiller@georgiahealthnews.com

By Andy Miller for Georgia Health News, 2012. | Permalink | Comment | Public Health

Mark Mulligan

HIV Vaccine Awareness Day occurs every May 18 to raise awareness of, and encourage participation in, HIV vaccine clinical trials in humans.

We need an HIV vaccine. Every year for 15 years, about 56,000 Americans have become newly HIV-infected. This number has not fallen despite behavioral education efforts.

Over the same period, HIV treatment has improved tremendously, and AIDS deaths are down dramatically, from 55,000 to 16,000 annually.

In a disturbing calculus, treatment success paired with prevention failure means the United States is adding 40,000 more people living with HIV each year. The global trend is similar: 900,000 more people are living with HIV each year. So a vaccine for HIV is a key missing prevention tool.

Earlier, candidate vaccines in four large clinical trials failed to prevent HIV infection or lower virus levels after infection. Then, in 2009, an HIV vaccine study of 16,000 heterosexual men and women in Thailand demonstrated — for the first time ever — a modest reduction (31 percent) in HIV infections in vaccinated people over a three-year follow-up period.

When the analysis was limited to the first year after vaccination, a 60 percent protection rate was observed, suggesting that a booster was needed.

However encouraging these findings are, the hard truth is that we are still several years away from a widely available vaccine. Sadly, that means millions more women and men will become HIV-infected before we have the vaccine we need.

Last week, a panel of experts recommended that the FDA approve preventive use of the HIV medication Truvada, a combination of tenofovir and emtricitabine, in people who are HIV-negative but at high risk of infection. Emory scientists were the inventors of emtricitabine, which has helped transform treatment for infected individuals over the past decade. The FDA, which usually accepts such expert panel recommendations, will decide by mid-June on Truvada for prevention.

The prevention pill could be a supplement to — but not a replacement for — condoms, counseling, and safer sex. If it is not taken daily, its effectiveness goes down. One barrier to broad uptake is the cost, $14,000 per year, and there’s more we need to learn about its long-term side effects and the development of resistance.

Still, it is good to know that we may soon have a new FDA-approved HIV prevention tool for some truly high-risk people who can afford the drug and take it faithfully. Ultimately, however, we still need a vaccine!

The Emory Vaccine Center at Emory University, along with the Yerkes National Primate Research Center, is a global leader in laboratory-based HIV/AIDS vaccine research. The Hope Clinic at Emory conducts cutting-edge AIDS vaccine clinical trials in volunteers who are not HIV-infected.

On Friday, HIV Vaccine Awareness Day, consider becoming a local participant in these trials at the Hope Clinic. If you are not infected with HIV, this is a powerful way to — literally — roll up your sleeves, take a shot, and help fight HIV.

To learn more, visit www.hopetakesaction.org or call 877-424-HOPE.

Or, you can support HIV vaccine research through advocacy. One community organization that for 10 years has been a model of support and tireless fundraising for HIV vaccine research is Action Cycling Atlanta, which puts on the AIDS Vaccine 200 Bike Ride this weekend. Learn more at http://actioncycling.kintera.org

It’s inspiring that more than 200 people are choosing to bike 200 miles this weekend to fight AIDS.

Dr. Mark J. Mulligan is a professor of medicine within the Division of Infectious Diseases at Emory University. Dr. Mulligan serves as co-director of the Clinical Core for the Emory Center for AIDS Research. He is also executive director of the Hope Clinic of the Emory Vaccine Center, a human research clinic focused on clinical trials of vaccines and other prevention technologies, translational immunology studies, education and training the next generation of vaccine researchers.

By Mark Mulligan for Georgia Health News, 2012. | Permalink | Comment | Public Health

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In past centuries, the disease killed millions of Americans, including historical figures such as President James Monroe and Eleanor Roosevelt.

Then, in the 1940s and ’50s, effective drug therapies were developed, and experts predicted the eventual elimination of TB.

Yet TB remains a massive killer worldwide, accounting for 2 million deaths annually. And it’s the leading cause of death for people infected with HIV, including in the United States.

The U.S. rate of TB has been declining. Last year, a total of 10,521 new tuberculosis cases were reported in the U.S., an incidence of 3.4 cases per 100,000 people. That’s the lowest rate recorded since national reporting began in 1953, the CDC says.

But Georgia’s tuberculosis rate, though dropping, is still higher than the national average. Georgia reported 347 TB cases (3.5 cases per 100,000 population) in 2011, a 16 percent decrease from 2010.

The disease in the state is largely centered in three counties in metro Atlanta — DeKalb, Fulton and Gwinnett.

The state Department of Public Health reports that in 2010, the most recent year with available data for population estimates by race and ethnicity, the highest TB case rate was in Asians (24.1 per 100,000), followed by Hispanics (8.2 per 100,000), and non-Hispanic blacks (7.1 per 100,000).

The cost of containing a live outbreak can be ‘‘phenomenal,’’ says state Sen. Renee Unterman, who represents a Gwinnett district. Unterman’s advocacy helped inject an extra $350,000 in the state budget for treating TB in those three counties.

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“In Lilburn, where I grew up, we started seeing a rising incidence of TB,’’ Unterman says.

Two years ago, 50 students and faculty members at Lilburn Middle School tested positive for exposure to tuberculosis during a public health screening. Here’s an AJC article from 2010 about the school’s TB problem.

Most infections become the non-contagious and asymptomatic latent TB. One in 10 of those cases, though, converts to the contagious, symptomatic, active TB disease.

In Gwinnett, as well as nationally, the disease hits foreign-born residents disproportionately hard.

Alana Sulka, director of epidemiology for the Gwinnett, Newton and Rockdale public health district, says many TB patients “come from areas that are high in TB.’’

There is also a higher incidence in prisons and jails, Sulka says.

Labor-intensive monitoring

In DeKalb County, where the highest number of TB cases in Georgia has occurred, the district health director wrote a letter in October to the state’s commissioner of Public Health, requesting funding for legal expenses incurred for TB confinement cases.

If people have active symptoms, they are confined for four to six weeks in a quarantine-like situation.

The letter gives a stark picture of the disease in DeKalb.

“DeKalb TB cases are among the most complicated, with 67 percent of the individuals being foreign-born, representing 18 countries; and thereby, presenting with language and cross-cultural needs,’’ wrote Dr. Elizabeth Ford, the health director for DeKalb.

Of the TB patients in fiscal 2010, 18 percent had HIV, and 12 percent were homeless, ‘‘and a significant number had a history of alcohol and drug abuse,’’ Ford said in the letter.

The primary cost of the public health TB response involves increased staff workload and time. Public health officials manage active cases by using direct observed therapy, where staffers must watch the patients take their medications. Failure to take medication can harm the patient and even contribute to development of drug-resistant infections.

This need for one-on-one monitoring has strained the public health budgets. “There’s not enough public health personnel to deal with the situation,’’ Sulka says. Here’s a GHN article last year on the public health financial burden.

Gwinnett’s rate dipped last year, Sulka says, but it remains about double the national rate.

The TB case count in Fulton County dropped from 81 in 2009 to 45 in 2011. Fulton County Department of Health and Wellness credits prevention efforts focused on the homeless population, especially people who are HIV-infected.

“This included major screenings for active and latent TB at some of the larger shelters in the county,’’ says April Majors, a spokeswoman for the public health agency.

Poverty is a key factor

Meanwhile, important research on TB is under way in Atlanta.

Jyothi Rengarajan, a TB researcher at the Emory Vaccine Center, says that she came to Atlanta mainly because it had a relatively high incidence of the disease, which would aid her research.

Rengarajan and other researchers are studying people who have latent TB infections but no active symptoms. They are analyzing how the immune system responds to infection. A goal is to be able to predict which healthy person with a latent infection will progress to active TB disease.

Many metro Atlanta patients end up at Grady Memorial Hospital, the state’s largest safety-net hospital.

Dr. Susan Ray, who is working with Rengarajan on the TB research and practices at Grady, says the disease typically surfaces in people living in crowded conditions, those with HIV, and people with substance abuse problems.

The average person does not need to fear being infected with TB, Ray says.

(Eleanor Roosevelt, though a wealthy woman all her life, made a point of visiting and working with the poor and the sick, and traveled abroad extensively, and probably was exposed to TB during those visits.)

The Georgia public health system is doing a good job on tuberculosis, Ray and Rengarajan say.

“This is a disease of poverty,’’ Rengarajan says. “If you eliminate poverty, you eliminate TB.’’

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It’s a problem everywhere, including Georgia. Even in rural areas, such problems can often be acute.

Take thinly populated Madison County, in northeast Georgia. “We have a lot of kids who go to parties and drink excessively and then they make wrong choices. A lot of times they’ll get drunk and have sex and not even remember it,” said Wanda Strickland, a nurse practitioner at the Teen Matters clinic and the Madison County Health Department.

Some are exposed to sexually transmitted diseases; others seek the “morning after” pill to prevent pregnancy.

In the county’s most recent Behavior and Risk for Teens (BART) survey in 2003, 45 percent of the 17- and 18-year-old high school students surveyed said that they had consumed alcohol, and more than half had engaged in sexual intercourse.

Unfortunately, some parents not only fail to protect their children from the risks that drinking brings, but may actually make it easier for teenagers to get drunk. The drinking then opens the door to other public health problems, like teen pregnancy and STDs.

A 15-year-old Clarke County ninth-grader recalls that when living in Madison County, many teens were provided alcohol at regular parties at a local adult resident’s home. ‘’Sometimes I’d just sleep in the hammock on the porch,’’ the ninth-grader says.

Renee Womack, a concerned Madison County mother, adds, “It’s a major thing, parents partying with their kids. It’s like ‘monkey see, monkey do.’ ”

But there’s no reason to think rural Madison County is unique.

The federal Substance Abuse and Mental Health Services Administration says teens drinking with parents occurs nationwide. It’s a problem both in terms of teenagers getting access to alcohol, and also in the higher rates of alcohol problems among those whose parents have drinking problems, the agency says.

More than 40 percent of the nation’s estimated 10.8 million underage current drinkers (persons aged 12 to 20 who drank in the past 30 days) were provided free alcohol by adults 21 or older, according to a nationwide report in 2008 by SAMHSA. The study also indicates that one in 16 underage drinkers (6.4 percent or 650,000) had been given alcoholic beverages by their parents in the past month.

The problem of teenagers drinking with their parents cuts across all lines – geographical, racial, and socioeconomic, says Neil Kaltenecker of the Georgia Council on Substance Abuse.

Meanwhile, teen sexual behavior is a statewide problem. Georgia is ranked 15th among the 50 states in number of chlamydia infections (459.3 per 100,000 people), according to 2010 statistics compiled by the CDC.

The state also has the 13^th highest teen birth rate in the U.S., though that rate is declining, says the Georgia Campaign for Adolescent Pregnancy Prevention.

In Georgia, the evidence of teens drinking with parents is often anecdotal. Parents don’t talk openly about the issue because providing alcohol to minors is illegal.

An 18-year-old high school student says teens in Madison County drink out of boredom. “There’s really not that much to do, so we just all get together and drink and have fun,” the Madison student says.

Such “fun” can have long-term, serious consequences. Research links early alcohol use to increased drug use, school failure, poor judgment, accidents, violence, suicide, unprotected sex and unplanned pregnancy. One kind of risky behavior leads to another. For many people, such behavior helps perpetuate the cycle of poverty.

And people who begin drinking alcohol before the age of 15 are six times more likely than those who start at age 21 and older to develop alcohol problems, SAMHSA says.

Amanda Dickey is working on a master’s degree in Health and Medical Journalism at the University of Georgia. She obtained her bachelor’s degree in English from Armstrong Atlantic State University in Savannah, and interned for six months at South Magazine, an award-winning publication based in Savannah.

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