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.
Day 3 - Psychosocial issues and HIV; ageing with HIV; effects of lipodystrophy; DTG and neuropsych effects
This morning’s session was largely about psychosocial issues in people living with HIV.
Moisés Agosto-Rosario (an educator and advocate for people living with HIV) spoke about communication and ways in which we can improve this. He emphasised that it must be patient-focused, and must consider the sensitivities of those “key groups” at risk of HIV (sex workers; MSM; PWID; trans people; CALD people). He finished by stating that by 2020, 70% of people living with HIV will be >50yo (I imagine that this was a US statistic, but he didn’t specify), so we must be prepared for the increase in comorbidities that’ll come along with an ageing population living with HIV.
David Stuart (from Dean Street Clinic, London) spoke about the change in culture of the MSM community, with specific reference to:
- The social scene (hookups often through apps as opposed to in person)
- The drugs used (crystal/GBL/mephedrone in London)
- Risk-taking behaviour
Of the HIV-infected patient group they see, several have died in the past 12 months – but all were from drug-related issues (not from HIV/AIDS), highlighting the importance and risk of drug use in this population. He also emphasised the importance of doing “well-being” checks at each visit, including social and emotional well-being.
Changes in morbidity/mortality/HIV care – a cohort study over 10 years in France.
Charles Cazanave spoke about research they’re doing in Aquitaine, France, with the ANRS CO3 cohort, to assess how the needs and morbidity of people living with HIV change over time. They had a cohort of n=2138 that they recruited in 2004 and followed until 2014, following their HIV-related characteristics, as well as other patient factors and co-morbidities.
- 71% male (40% MSM)
- 52% were over 50 in 2004 (and obviously 62% in 2014)
- 91% had HIV VL<50 in 2014 (compared with 51% in 2004)
- 72% had CD4>500 in 2014 (c/w 44% in 2004)
- ART regimens changed little between 2004 and 2014 (except integrase inhibitors being used in 6.5% in 2014).
- Dyslipidaemia rates increased by 40% and hypertension by 37% over the 10 years
- Cardiovascular (increased by 6.1%) and CNS adverse events increased over time; rate of people with EGFR<60mL/min increased by 5.1%; those with Framingham score indicating high risk increased.
Unfortunately there was no control group with which to compare these increases. However they concluded that monitoring for and management of co-morbidities is imperative in an ageing population with HIV.
Effect of lipodystrophy on morbidity/mortality.
Esteban Martinez presented research on the connection between lipodystrophy on risk of morbidity and mortality – their hypothesis was that lipodystrophy may increase the risk of comorbidities/mortality in people living with HIV.
They studied a population (n=494) that began CART between 1996 and 1999 – this CART initially involved 2 x NRTIs and at least 1 PI. 76% were men; 28% were MSM; 39% IVDU. Follow-up was until Dec 2015 or death (14%) or loss to follow-up (21%).
- 24% had lipoatrophy
- 4% had lipohypertrophy
- 18% had lipodystrophy (both lipoatrophy and lipohypertrophy)
Analysis of death rates, morbidity and lab testing by the end of Dec 2015 revealed:
- Fewer AIDS events and fewer deaths in those with LA/LD, however no association with lipohypertrophy (however note the small number of people with lipohypertrophy).
- Less hepatic decompensation in those with LA/LD.
- Hypertension/diabetes rates increased in those with LD/LA/LH.
Conclusions were, unsurprisingly, that lipoatrophy was a proxy for effective CART and viral suppression, so morbidity/mortality overall less in this group.
Dolutegravir and cessation due to neuropsychiatric effects.
Michael Sabranski presented an analysis of all those beginning integrase inhibitors in Germany between Jan 2007-April 2016. All discontinuation reasons, start and stop dates were analysed.
- In those that took dolutegravir, other covariables were analysed.
The study found that:
- The discontinuation rate of dolutegravir due to neuropsychiatric adverse effects was almost 6% within 12 months – this rate was higher than that reported in RCTs (and higher than for raltegravir/elvitegravir)
- Women, older patients and patients who simultaneously initiated abacavir had a 2-3 fold higher risk of DTG discontinuation due to neuropsychiatric adverse events.
- Such adverse events were reversible and not severe.
It was acknowledged that a higher rate of people ceased DTG in 2016 (after research had already come out linking DTG with neuropsych side-effets. However even when those patients were removed, the relationships listed above were still significant.