ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

Peripheral Arterial Disease. 

HIV infection and the risk of peripheral arterial disease; an observational, longitudinal cohort of HIV positive U.S. Veterans matched 1:2 with HIV- uninfected veterans matched for age, race, ethnicity and site.  The sample was greater than 90,000.

The investigator presented data from 7 years of observation of this very large cohort. The participants were followed for peripheral arterial disease (PAD), death or their last follow up date.

Cumulative incidence of PAD was calculated and adjusted for confounders. A regression model was used to examine the association between HIV positivity, CD4 count and PAD after adjusting atherosclerotic risk.

In this study, the HIV positive veterans had significantly higher rates of peripheral arterial disease when compared with HIV uninfected veterans.

The speaker encouraged checking for ankle/feet pulses as PAD is often not diagnosed – this seems like a extraordinarily simple ‘practice-changing’ intervention for primary care.

An absence of a pulse should prompt vascular referral. Smoking cessation obviously remains a vital health intervention. A low CD4 cell count was also a strong predictor of PAD, with almost a 2-fold increase in the risk. Importantly, a CD4 count of greater than 500 showed no increase in risk. Lipid lowering treatment will be part of a future analysis and was not examined in this paper.

Tagged in: 2017 IAS Conference

I attended this one hour punchy poster discussion session on Monday lunchtime. It covered a wide variety of topics including cardiovascular, renal, lipids and brain function, chronic pain and mental health in people living with HIV. It included an Australian presenter Dr Nicholas A. Medland who concluded that "Fanconi syndrome occurs at a late stage of antiretroviral treatment" and that it is "an uncommon but not rare" outcome. That "Ritonavir use increases the incidence by 5 times". And there was a memorable point to take away that monitoring is important and simple (once to twice a year urine dipstick test) even in long term patients who do not appear to be at increased risk.

Following this there was a talk by Dr Felicia Chow regarding higher HDL and improved brain function. There were 988 participants in the study and 80% were male. 27% were taking a statin medication and 36% an antihypertensive medication. I could relate to the frustration behind the questions from the audience regarding what can you actually do to increase HDL levels. As getting active, losing weight, healthy diet, reduce alcohol and stop smoking can be a slow process but it was a reminder once again to continue to encourage these lifestyle changes.

After this was an interesting talk regarding non pharmacological managment of chronic pain by Jordan E. Lake from the University of Texas. 55 participants who were aged fifty years or older and who were living with HIV. They had chronic pain for more than 3 months (mainly osteoarthritis and/ or peripheral neuropathy) and were randomly assigned to one of three twelve week treatment options. Either 1) Tai Chi (chosen for its ability to be used by even the frailest of patients) and Cognitive Behavioural Therapy and motivational mobile phone texts or 2) a support group or 3) no intervention. 

The conclusion was that substance use was reduced by both the support group and Tai Chi/CBT/SMS intervention and pain relief and physical function improved by the Tai Chi containing intervention. This reinforced the benefit of patients living with HIV having a chronic disease management plan and team care arrangement for easier access to an Exercise Physiologist and Psychologist from their General Practitioner.

 

Tagged in: 2017 IAS Conference

Dr Marcos Davi G. Sousa Specialist in Infectology, Federal Hospital of the Servants of the State of Rio de Janeiro presented a case history of a male, unfortunately he didn't state how long the patient had been HIV +.

* 51 years of age

* COPD

* alcohol dependant 

* very poor ARVT compliance

He had previously been treated for Tuberculosis, mycobacterium kansasii and mycobacterium avium, but continued to experience poor health, and poor compliance on ARVT.

He was tested and treated for M. intracellulare in Jan 2015, then tested positive for "atypical mycobacteria" in Sep. 2015.

In Nov 2015 a positive culture identified M. colombiense, the first isolate of this species in Brazil. It is a slow growing  type of  mycobacterium that infects both immunocompetent and immunocompromised people and was first isolated in Bogota, Columbia in 2006. Importantly, infection can mimic tuberculosis.

Treatment provided was the same for tuberculosis and should have continued for one year after the last negative test, but the patient continued to be non compliant with treatment and apppointments. Resistance testing was not yet available, and the outcome for the patient was not presented. 

 

The ageing of PLWHIV calls for new models of primary care.

Rajasthan, R, Malaysia ; HIV and ageing Study.

 

One of the emerging challenges is the ageing cohort of PLWHIV within Australia. Many of these individuals have complex co-morbidities requiring experienced clinicians and team based models of care.

Dutch data indicates that 2 of 3 HIV positive individuals within Holland will be aged >50 by 2025. Similar trends are expected in Australia.

There were many sessions and posters looking at co-morbidities and ageing.

Many abstracts highlighted the increased prevalence of CKD, atherosclerosis, peripheral neuropathy, neurocognitive decline, diabetes and osteoporosis in PLWHIV. Ruzicka D Japan, Rajasuriar R Malaysia, to name a few of the many presenters.

Reena Rajasuriar presented findings from the Malaysian HIV and ageing Study.

Attempts were made to adequately match study participants. The concept of functional age was a central tenant of the design. Prior studies were highlighted for lack of adequate controls and use of subjective, poorly validated measuring tools. Dr Rajasuriar commented that single entities are often used to measure the ageing syndrome.

The Malaysian study focused on the multi factorial nature of ageing. The use of comprehensive geriatric assessments were utilised to reduce subjectivity bias.

All 10 markers of ageing were increased in the HIV positive arm compared to matched HIV negative participants.

  • 2.5 times reduction in QOL indicators.
  • 4 fold increase in mortality
  • 5 fold greater utilisation of health services.
  • Significantly more sarcopenia and functional disability.

New models of care were called for throughout the Asia Pacific region. In particular multidisciplinary teams, including but not limited to, social workers, dietitians, psychologists, nurses, GPs, physiotherapists, podiatrist and exercise physiologists.

Comprehensive geriatric assessments were heralded as ideal.

Much panel discussion was generated through audience participation

  • Is this a realistic concept?
  • Is the process clinician driven or patient driven?
  • What management strategies are cost effective?
  • How do we manage the increasing burden of subcortical neurodegeneration?

This session was very informative generating much discussion amongst my Australian colleagues.

As demand for complex services increase service innovation will be required.

Australia is proposing a new patient centric and patient driven model of care. Health care homes as primary care coordinators are also a central  theme. This model is well suited to providing innovative care to the ageing population of PLWHIV.

Management of traditional lifestyle risk factors remains central to managing cognitive decline.

Focusing on functional age is increasingly seen as a more useful measure of healthcare needs rather than numbers of co-morbid conditions. 

 

 

 

 

Tagged in: APACC 2017

 

A few “Snapshots” from the Inflammation and Age-related Complications session, of interest:

 

1.       An update of D.A.D. data looking the association of cardiovascular disease and contemporarily used protease inhibitors, Atazanavir and Darunavir: Analysis looked at a prospective 7 years’ median follow-up (IQR 6.3 – 7.1) of 35,711 participants with 1,157 (3.2%) of participants having cardio and cerebro-vascular events (incidence rate 5.3/1000 PYFU (95% 5.0 5.6).  The analysis, with which we are now familiar, looked at crude incidence rates of CVD per 1000 PYFU stratified by cumulative use of ATV/r and DRV/r, and MI and Stroke separately. In this analysis, the cumulative use of DRV/r, but not ATV/r was independently associated with a small but increasing risk of 59% per 5 years’ exposure. The strength of the association is of a similar size for the older PIs but in contrast, does not appear to be modified by dyslipidemia.  We were reminded to exercise caution in interpretation as the study is observational only, and there are risks of unmeasured confounding. (L. Ryom et al CROI 2017 # 128LB.)

 

2.     Investigators in the North American AIDS Cohort Collaboration on Research and Drugs (NA ACCORD) looked at the incidence occurrence of Type 1 MI (atherothrombotic coronary event from plaque rupture) and the association with modifiable traditional risk factors by analysing the Population Attributable Factors (PAF) for MI.  They concluded that 43% of cases of MI in this cohort could have been avoided if these individuals did not have an elevated cholesterol, holding all other variables constant, 41% of MI were avoided by treating hypertension and 38% by smoking prevention. (K. Althoff et al CROI 2017 # 130.)

 

3.       A further analysis from the D.A.D cohort looked at cessation of cigarette smoking and the impact on cancer incidence. (N= 242 cases of lung cancer, and N=487 cases of smoking related cancers, excluding lung).  There were limitations in the study relating to the collection of cessation dates, intensity, duration or pack years unfortunately. However, the investigators concluded that smoking related cancers, excluding lung cancer, rapidly declined following cessation. Lung cancer incidence appeared to remain elevated in HIV patients several years after cessation, which is in contrast to studies in HIV negative individuals. (L. Shepherd et al CROI 2017 #131.)

 

Tagged in: CROI 2017