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.

 

I attended the talk by Dr Janine Trevillyan titled: Management guidelines for HIV-related Co-morbidities result in increased screening but no change in Primary Prevention Implementation.

Janine described an audit conducted at Alfred Health, Melbourne comparing compliance with local recommendations/guidelines for screening and management of cardiovascular risk factors before and after release of the guidelines.

The audit showed that compliance rates for sticking to guidelines for statin use pre and post intervention were similar and there were no changes in patients receiving a statin pre and post intervention.

Although routine blood pressure monitoring increased from 65% pre intervention to 88% post intervention, there was no change in antihypertensive use and no observed improvement in systolic blood pressure post intervention.

One interesting finding of the audit was that renal function was borderline (eGFR 60-90mL/min) in 51% of patients. Janine mentioned that this will be something that will be followed up as the implications of these findings are unclear and it will be interesting to see where the renal function of these patients is at in a few years.

Overall, the audit found that implementation of recommendations/guidelines can increase screening rates for cardiovascular risk factors but this did not translate into improved implementation of primary prevention therapies. Janine mentioned that a change in the model of HIV care provision may be needed.

These findings are important to me as a pharmacist involved in the care of patients at an ambulatory HIV clinic. We have recently implemented a pharmacist review at annual health checks for patients taking combination antiretroviral therapy (cART) in my clinic. See poster number 12. Impact of a Pharmacist review during annual health checks in patients taking combination antiretroviral therapy.

A pharmacist review during annual health checks may help to identify patients not meeting the recommended cardiovascular risk factor targets, bring these to the attention of the doctor and assist with their management.

 

 

 

 

Tagged in: HIVAIDS2015
What do we know that we do not know?

On Thursday afternoon, under Theme B: Antiretroviral Therapy, things moved up a gear, with back to back presentations touching almost every aspect of the ART and the long term complications. Dr David Nolan from Royal Perth Hospital gave a thoroughly captivating revision around HIV treatment. He gave a brief account of the pre, early and late HAART treatment options, how things have evolved in terms of the choices, co morbidities, tolerability and toxicity.

He reflected on the contemporary challenges around decision making in clinical practice, how we can factor in the newer therapies and novel diagnostic approaches in our existing treatment and screening paradigms.

What do we know that we do not know?

David argued that despite of having potent ARTs with superior virological efficacy, we don’t have enough evidence to guide us on how to screen, monitor, and subsequently manage the emerging associated co morbidities including HIV neurocognitive impairment, chronic immune activation, and increased risk of malignancies.

What don’t we know that we do not know?

David threw up some very topical questions with both ethical and public health implications. Does it matter that there are things we don’t know? Should we change ART regimen just because we have newer drugs? What if HIV patients with sustained viral suppression do not want to change their old medications?

These are very complicated and yet practical questions, and we still do not  seem to have a simple answer. With discovery of newer, safer and simpler ART regimen, we are likely to find ourselves in a situation where we might simply not have enough evidence to guide clinical choices when it comes to changing or switching regimen. In that case he concluded that we might simply accept the fact that there will always be unknown unknowns.

He also discussed the rationale of ART treatment intensification (using Maraviroc for example) and what should be realistically expected. He pointed out that current evidence indicate that treatment intensification makes little difference in some of the important prognostic clinical parameters like viral load and immune activation markers. It does not appear to impact on viral reservoirs and residual viremia which tend to be established early following primary HIV infection. He posited that, in absence of robust evidence for treatment intensification, the seemingly logical approach will be to start treatment early following seroconversion.

This was arguably one the most thought provoking presentation I have attended in this conference. It raises some of the difficult issues clouding the field of HIV and ART treatment and long term treatment outcome. Obviously, there are things that we do know, and things we have been doing well in improving our knowledge and understanding of how ART works.

Perhaps, It is time to start thinking about how do we integrate the use of monocyte activations markers like sCD14, in the standard of care for our patients.  For the next few years it will be pretty much about the known unknowns and the unknown unknowns that will really determine if we are going to win another important dimension of this epidemic when every HIV patient has undetectable viral load.

Blood Pressure Targets IN HIV+ patients

Again another very interesting session from a GP perspective. 

Dr Shanti Narayanasamy discussed the challenge of meeting BP targets in HIV positive outpatients.

The background to the problem is concerning; high BP accounts for 45% of heart disease mortality and 51% of stroke deaths. Rates of hypertension in people living with HIV in Australia is approximately 20-25% and those affected have higher rates of myocardial infarction than the general population.

This cross sectional, retrospective study examined whether HIV positive patients attending an outpatient clinic who were diagnosed and treated for hypertension were meeting blood pressure targets as per the Heart Foundation guidelines.  Please see below:

People with proteinuria >1 g/day (with or without diabetes) < 125/75

People with associated condition/s or end-organ damage:* • Coronary heart disease • Diabetes • Chronic kidney disease • Proteinuria (> 300 mg/day) • Stroke/TIA < 130/80

People with none of the following: • Coronary heart disease • Diabetes • Chronic kidney disease • Proteinuria (> 300 mg/day) • Stroke/TIA < 140/90 or lower if tolerated

Of the 69 patients studied, 97% studied were male. Of these 48% met the target BP and 59% had end organ disease from hypertension. Most of these patients were treated with ACE-i medications (no: 39). Most patients were treated with monotherapy (70%) and 30% were taking more than 1 anti-hypertensive. Of the patients that had end organ disease only 68% had seen either a cardiac or renal specialist as per the guidelines. Of those that had seen a specialist; this was correlated with better BP control.

Those patients that were virologically suppressed had better BP control. This could be attributed to overall better medication compliance. Older patients also had better BP control.

This raised the question of whether there was some reluctance/inexperience of the ID physicians or general practitioners involved in these patients care to up-titrate hypertensive management when necessary.

Certainly this appears to be an issue that is likely faced in a number of different settings and was a great way to raise the awareness of meeting BP targets and involving specialist opinion when required.

 

Tagged in: HIVAIDS2015

I really enjoyed the sessions today on co-morbidities and as a S100 general practitioner found this very useful. The discussion re bone health was especially interesting to me given a number of my patients have low BMD.

Professor Jennifer Hoy outlined practical management and screening of bone disease in HIV. Osteoporosis is a silent disease until fracture occurs and people living with HIV have a higher risk of low BMD and fragility fractures than the general population. This is likely due to lifestyle risk factors, low vitamin D levels, HIV induced inflammation and the effect of ART.  The question is who should be screened? Which tool should be used? When should we start screening and how often should we be screening our patients?

Who should be screened? All HIV positive individuals over the age of 40years, those with a history of fragility fractures, those taking corticosteroids for more than 3 months at doses of greater than 5mg per day and prior to ART initiation.

Which tool do we use ?Using the FRAX calculator ( https://www.shef.ac.uk/FRAX/tool.aspx?country=31) calculates the ten year probability of fracture with BMD. However the FRAX calculator while useful has not been validated in the HIV population. High risk patients should have a DEXA scan. However DEXA scan can only be accessed if there is a history of previous low BMD or previous fragility fracture/fracture with minimal trauma, if there is a history of chronic liver or renal disease, proven malabsorptive disorder, history of rheumatoid arthritis, thyroid excess states and in patients over 70 years of age. It does make it difficult if your patient does not fall into this category and alternatives to DEXA include the 'Measure Up Mobile Dexa Bone Health'unit, quantitative CT scan and heel ultrasound.

DEXA screening intervals are based on the baseline screening result. For normal-mild osteopenia this would be every 5 years and for more advanced osteopenia every 1-2 years. Professor Hoy mentioned that there was insufficient evidence for more frequent screening for those on certain ART regimens i.e. tenofovir.

In terms of treatment for those with fragility fracture or low BMD this includes:

- adequate dietary calcium

- ensure they are vitamin D replete

- lifestyle modifications ie smoking cessation/alcohol reduction

- exclude secondary cause of low BMD

- discontinue or change ART regimen if appropriate

- initiate bisphosphonates under the same criteria as general population

This was a very informative session and information that will be very useful in my position as a GP

Tagged in: HIVAIDS2015
Toxicities

Lovely morning plenary by Paddy Mallon discussing ART toxicities. 

With the lofty ambitions of 90-90-90 upon us, there will be increasing numbers of people starting ART at higher CD4 counts. Given that all the regimens we would be prescribing have excellent efficacy, toxicities & tolerability is now firmly back in the spotlight. 

Interesting point comparing tolerability and toxicity; in general, tolerability (side effect profile) is easier to identify and often brought up by the patient themselves. Patients have been known to put up with mild/moderate side effects if they are satisfied with their regimen. 

Toxicities are often silent which means as clinicians we need to have appropriate monitoring strategies if we are to stay ahead of the game. 

Paddy briefly talked to the PIs and lipoatrophy (now essentially obsolete), as well as some PK data suggesting the PIs may not have the level of association with insulin resistance or CV risk once thought.

Efavirenz got a mention - it's definitely out of favour now, ostensibly due to its side effect profile (dreams, rash, dizziness), though some of the data for abnormal dream is fairly subjective. 

The main toxicities Paddy focused on were the big 3 silent toxicities due to the NRTIs

1. CV risk due to abacavir:

- Paddy's opinion is that the the evidence is conclusive with a number of studies, including the recent US NA ACCORD (palella 2015) showing a hazard ratio of 1.95 for AMI.

2. bone and kidney health due to tenofovir

- bone health seems to be predominantly lost in the initial 48 weeks on ART, implying that it is the ART, rather than HIV alone, which leads to decreasing BMD and subsequent increased fracture risk. Cessation of TDF leads to increased BMD.

- renal function - consideration for TAF is important - the cost will need to be taken into account.

And into the future?

- cost is and will remain an issue

- should we drop the NRTI altogether?

- the silent toxicities will become less silent as our HIV population ages

 

Thanks for a great summary of the topic

 

 

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