Prostate cancer screening was discussed in the context of HIV at a presentation today by  L. Shepherd.

Her group showed some PSA difference perhaps in HIV positive men.

The study used conditional logistic regression models to investigate potential relationships between markers and prostate cancer. The suggestion from the study was that prostate cancer may occur at lower PSA levels in HIV positive men.

I found this suggestion remarkable given that the guidelines for the general population are so hotly debated. In this study there was no detail about how prostate cancer was defined.

It was not clear whether this was a true "screening" PSA process or whether these were symptomatic men.

 

This data will not change my view about PSA screening in all men positive or negative.

pneumocystis jiroveci revisited.

This afternoon session was of some clinical importance for those of us that look after patients whose CD4 count has never fully recovered despite many years of viral load below detection limits.

This Swiss cohort study produced elegant data with a combination of CD4 count and viral load as risk predictors of recurrent pneumocystis pneumonia.( H. Furrer)

This is consistent with the theme apparent in a lot of the presentations at this conference, of the ongoing problems associated with immune dysregulation from persistent viraemia.

In summary, patients with a CD4 count of 100 and persistent viral loads below detection limits have less risk of pneumocystis pneumonia than patients with a viral load of 400 and persistent moderate level viraemia. When I get hold of the elegant graphs I will try to post them.

 

This morning's meet the experts session about drug interactions was very interesting. There are an enormous number of potential drug interactions but the significance of many of them is unknown.

New drugs are being added to the database every week.

We will be faced with a large number of patients on multiple medications and particularly with the co-infected some clinical dilemmas.

The key useful points and questions for clinical care in the primary care setting are:

1. Are the other drugs necessary?

For instance statins and low-level antihypertensives could be ceased for a 12 week treatment course.

2. Are there any alternatives with less or no predicted interactions?

If so switch

Can the DDI be managed?

If the answer is yes then dose.adjust and monitor for toxicity. There was some discussion about trying to monitor for efficacy which is a little more difficult but very important.

If the answer is no

- the risk needs to be explored and discussed with the patient to decide whether the risk is worth taking.

A very valuable clinical point was made that a large number of patients with HIV on therapy have other medications with known DDI's in the current regimen prior to starting hepatitis C treatment. These probably do not have to be approached fearfully as they have been already sorted out.