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.

The next session I attended was an industry sponsored session on Maturing Patients, Maturing therapy: Multidisciplinary management in HIV.  The session on management of Cancer in HIV by Christine Katlama (Professor of Infectious Diseases and Head of the HIV Clinical Research Unit
Department of Infectious Diseases France) & Jean-Philippe Spano (Professor in Medical Oncology, in the Department of Medical Oncology of Pr. David Khayat at the Pitié-Salpétrière Hospital in Paris, France) highlighted the increasing medical issue of people living with HIV and cancer diagnoses.  Amongst some interesting case studies, the main points discussed were that viral-induced cancers are more prevalent in HIV positive patients compared with HIV negative patients, the impact of smoking is excessive and needs addressing and multidisciplinary team approaches are extremely important to maximise the therapeutic management of HIV patients with cancers.

 

They demonstrated a great example of this collaboration in the form of a 6 weekly web-conference that they have set up in Paris between Oncologists, HIV specialists, pharmacists and immunologists where they discuss cases and ensure any possible treatment interactions between ART and chemotherapy are evaluated by experts as well as consideration of the possible benefits of new immune therapies. Whilst perhaps not the direct purpose of the session I found the take home message for me was thinking about the importance of cancer screening and prevention in the comorbidity assessments of stable HIV positive clients that nurses are increasingly involved with.  Smoking cessation should be continually encouraged and revisited at every possible occasion in a supportive way as unsurprisingly tobacco smoking is attributable to many of the cancers diagnosed.

 

 

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

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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