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 plenary session this morning on this last day of CROI on “Cardiovascular Disease in HIV Patients: An emerging Paradigm and Call to Action” was presented by Steven Grinspoon – an endocrinologist.

 

He reminded us of the 35000000 people living with HIV and the increased cardiovascular risk (myocardial infarction, stroke and sudden death ) in HIV positive patients.

 

Several important points were brought up, some of which we may already aware of

 

·      CVD risk in HIV infected patients is beyond that predicted by traditional risk factors

·      Excess mortality from smoking has been seen in HIV positive patients

·      Although there have been studies in the past demonstrating cART being associated with diabetes, hypertension, lipid problems, increased platelet activity etc. and various studies associating cART with myocardial infarction, Steven emphasized the importance of looking at the the newer studies showing the positive effect of cART with respect to cardiovascular risk.

·      The SMART study and the potential mechanisms for beneficial effects of viral suppression on cardiovascular diseases including decreased I 6 and increased HDL.

·      Description of persistent viral replication and microbial translocation resulting in T cell activation and monocyte activation contributing to increased inflammation and increase cardiovascular risk.

·      Steven discussed studies showing increased capacity of cholesterol efflux with cART in patients with acute HIV infection and that the duration of immune suppression and nadir CD4 related to AMI

 

Further points

·      HIV is a state of immune activation and suppression with implications of atherogenesis pathogenesis

·      Immune activation relates to novel atherosclerotic phenotype in HIV. In HIV patients atherosclerotic plaques are inflamed and associated with immune activation markers.

·      Markers of monocyte activation are seen in HIV postive patients with CVD. Monocytes play an important part

·      There is immune activation at surface of high risk plaque

·      Increased rates of atherosclerosis in HIV have been seen by coronary CT angiography with the presence of these plague higher in HIV patients

·      HIV positive patients have increased higher risk morphological plaques with  the associated clinical implications for these high risk morphological plagues

 

Importance of identification of patients with disease, optimizing time and use of ART and safe effective strategies for primary prevention

 

He continues to discuss the importance of interventions addressing both traditional risk modification strategies and immune response risk factors. Immune interventions mentioned included CCR5 antagonists, IL antagonists, methotrexate, statins, renin-angiotensin blockers

 

He concluded the need of large RCT to inform clinical pactice. It is unknown if statins prevent CVD and should be recommended for the HIV population.

 

Discussion of REPRIEVE study a prospective RCT

 

In summary, traditional and non-traditional risk factors contribute to increase CVD risk in HIV manifesting itself with inflammed non-calcified high risk plaque in association with immune activation

 

I would encourage colleagues to look at the webcast when available.

 

Our HIV population in Australia is aging and we need to be continue being informed of the comorbidities associated with HIV especially cardiovascular disease.

Tagged in: croi2015

Following on from a symposium on "Current Issues in HIV -related Malignancies" yesterday (webcasts now available) during which HIV  associated malignancies were described as a worldwide epidemic, viral oncogenesis was discussed and a very rapid, high powered presentation on the advances and existing challenges of AIDS lymphoma to be followed immediately by the very humbling presentation on HIV malignancies in low and middle - income countries, it was of great interest to me to attend the themed discussion session on " Cancers in Young and Old and Lung Cancers in HIV"

It was useful to be reminded of the AIDS defining Cancers - Kaposi's Sarcoma, Non Hodgkin's Lymphoma and Cervical cancer and their associated etiological agents as well as the non AIDS defining cancers seen in HIV positive patients including Hodgkins Lymphoma, Anal, Lung and Liver carcinomas with their associated etiological agents.

In the US the most common AIDS defining cancer is Non- Hodgkin's Lymphoma. There have been recent decreases in Non AIDS defining cancers like Lung Ca and Hodgkin's Lymphoma but increases in liver and anal cancers. There was mention of prostate, breast and colorectal cancers although not in excess in HIV patients and with a greater association with ageing.  Aging in the HIV population needs to be considered.

5 studies were elegantly presented at this themed discussion 

  • Cancer in HIV infected Children: Record Linkage Study in South Africa
  • High Cancer Risk Among HIV Infected Elderly in the United States
  • Smoking Outweighs HIV- related risk factors for Non-AIDS Defining Cancers
  • High Frequency of Early Lung Cancer Diagnosis with Chest CT in HIV -Infected Smokers
  • CD4 Measures as Predictors of Lung Cancer Risk and Prognosis in HIV infection

Key points summarised from these studies

ART was found to reduce the risk of developing cancer in HIV infected children in South Africa and the early link to care as well as the early start of ART is emphasised to further reduce the burden of cancer in these children  

Elderly patients with HIV may have a higher risk for many cancers identified as HIV-associated in younger populations. The elevation of Non-Hodgkin's Lymphoma incidence in this population was notably lower in one of the studies possibly reflecting the high frequency of NHL subtypes less strongly associated with HIV in elderly adults. The increased risk associated with ageing and HIV together, in elderly patients infected with HIV, shows a sizeable absolute risk of cancer. The need for cancer prevention and screening in this population was emphasised.

Smoking cessation programs were emphasised amongst adolescents and young adults at risk for HIVV with suggestions that this could prevent up to 46% of non AIDS defining Cancers in HIV infected adults. This emphasises the importance of primary care involvement in this population. Using ART to preserve immune status, maintain HIV viral suppression and preventing AIDs defining illnesses could prevent only up to 6% of non AIDS Defining Cancers in HIV infected adults. So, effective interventions to reduce smoking were emphasised with a continued HIV treatment focus.

Interestingly , one study showed that early lung cancer diagnosis and nodule followup with chest CT was feasible in HIV infected smokers with detection of surgically curable cancers. This study raised a lot of discussion on screening for lung cancer. I would recommend you look at the webcast when available

Finally another study found several measures of recent and cumulative exposure in immunodeficiency associated with increased risk lung cancer.

Continued vigilance of the issue of malignancy in primary care and specialist care of HIV patients needs to be emphasised.

  1.  

Tagged in: croi2015

Wednesday 23rd July 2014

After a long wait to see Bill Clinton address a packed audience to encourage us to continue to implement the goals of the WHO (and who addressed the gathering as a ‘movement’ rather than a conference), sitting in the special session on antiretroviral management in 2014—an interactive case-based discussion with several prominent HIV and hepatitis specialists—almost seemed ‘easy’ rather than trying to solve the complex public health problems of the developing world.

At the completion of the session, however, we were brought back to reality by a sobering statement from an African doctor who did ask that perhaps the next discussions could take into account the limited antiretroviral options in developing countries with likely scenarios from those regions, hitting home to me just how lucky we are in the Australian treatment environment to have so many choices.

It was also pleasing to see that when asked about simplification regimens for simplicity sake that several panelists were of the opinion that ‘if it isn’t broken, don’t fix it’ as we may switch patients to a less tolerable regimen with poorer adherence and without past records we may run the risk of archived resistance. The concepts of a ‘lateral switch’, where a patient has been naïve to treatment and there is minimal risk to switch versus a ‘vertical switch’ where we may not know of past suppression or resistance profiles was also discussed.

Links to the various guidelines can be found below:

1. ASHM 2014 Antiretroviral guidelines

2. US DHHS Adults and adolescents antiretroviral guidelines

3. American Society for the study of liver disease and the Infectious Diseases society of America: guidelines for hepatitis C treatment

Two very interesting studies from the Kirby were also presented this afternoon.

Firstly, Ben Bavington presented results from the Opposites Attract study looking at behavioural risk compensation amongst couples in the study. ‘Behavioural risk compensation’ being the concept where there may be reduction in condom use due to perceived protection from antiretroviral medications.

Approximately 77% of the HIV negative partners perceived their HIV positive partners viral load was undetectable, which was largely in accordance with pathology results. This did seem to correlate with engagement in condomless sex with approximately 73% HIV negative partners reporting condomless sex (CLS) when they perceived their partner’s viral load to be undetectable and thus demonstrating risk compensation within this group. Amongst the HIV positive partners, however, approximately 90% were taking antiretroviral therapy so perhaps this gave a protective effect.

In a separate session, Andrew Grulich presented on results of the SPANC study. This is an interesting area in that there is a 30-50% prevalence of high-grade anal lesions (HSIL) in gay men.

Treatment is difficult with recurrence rates of 50% at 1 year with grade 3-4 side effects. Progression to cancer is also 1/400 per year in HIV positive men and 1/4000 per year in HIV negative men. Of men recruited into the study they found that 1 in 6 men will develop HSIL per year (16/100 person years) with a clearance of 42/100 person years over 12 months.

HIV positive men were more likely to have HSIL but there was no correlation with age. HSIL was also very uncommon in men without chronic HPV infection. Pleasingly, with the high clearance rates, he concluded that if HSIL is identified that it does not necessarily require treatment and could be observed.

Tagged in: AIDS 2014 IAS2014

Supplementing starters on ART containing Efavirenz and Tenofovir with 4000 iu Vit D, and oral calcium, reduced BMD loss by 50% in the first year, say ACTtG A5280. Expected elevations in both PTH and bone turnover were reduced. It at least suggests that those with low Vit D levels at initiation should be identified, and have this considered. Abstract #133

Tagged in: CROI2014

Excellent session at CROI Monday 4-6pm "Cardiovascular disease and other non-AIDS events: Epidemiology and Pathogenesis".

This session (which will be webcast) very successfully pulled together different presentations to give an update on the heart and vascular disease as well as other SNAEs (serious non AIDS events) in HIV.

The key messages were

1. Adjusted risk of myocardial infarct for HIV+ was 80% higher than HIV- controls (VACS - Veterans Aging Cohort Study of 68,000 HIV- and 31,000 HIV+) with similar mean age of incidence

2. Plaque formation in coronary arteries measured on CT was 80% higher in HIV+ (vs HIV- at risk) MACS cohort

3. HIV+ patients more likely to have plaque but also more likely to have "vulnerable plaque" - i.e. plaque which is soft, lipid rich, monocyte rich, subject to remodelling and less calcified (spotty calcification) - these plaques less stable, more likely to rupture and cause myocardial infarct or sudden cardiac death

4. Vulnerable plaque associated with inflammation and in HIV+ this is monocyte-mediated as measured by soluble CD163 (and CD16)

5. So, in HIV+, there is the traditional risk factor (smoking, lipids, hypertension) coronary artery disease as in the general population. Additionally there is an inflammatory monocyte driven process which could partially account for higher CVD in HIV.

 

 

Tagged in: CROI2013

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

ASHM ASHM