News from IDWeek 2013
Several thousand researchers, clinicians, public health officials, and others converged in San Francisco last week for IDWeek 2013, a combined conference of the Infectious Diseases Society of America, the HIV Medicine Association, the Society for Healthcare Epidemiology of America, and the Pediatric Infectious Diseases Society.
Although many speakers from the CDC were unable to attend due to the federal government shutdown, and a power outage at Moscone Center on Saturday morning forced cancellation of several sessions, there was still plenty of information presented on HIV, viral hepatitis, and other sexually transmitted infections. (IDWeek 2013 program and abstracts are available online.)
Twenty-five years after approval of the first antiretroviral drug, several presenters looked at the history, state-of-the-art, and future of HIV treatment.
The history actually came toward the end, with Myron Cohen from the University of North Carolina at Chapel Hill—who has worked in the field since the earliest years of the epidemic—giving a plenary lecture on “The Evolution of Antiretroviral Agents: From Survival to Prevention to Cure.”
Cohen is perhaps best known as the principal investigator for HPTN 052, a large trial in Africa which showed that HIV transmission was reduced by 96% when the HIV positive-partner in a discordant heterosexual couple started immediate antiretroviral therapy (ART) regardless of CD4 T-cell count. Hearing these results after working on the study for 20 years, he recalled, “was like winning Dancing with the Stars.”
Given this dramatic reduction, do people with HIV and their HIV-negative partners still need to practice safer sex? This was the topic of a lively debate between clinicians Roy Gulick and Paul Sax. Although both made well-supported arguments, two-thirds of the audience agreed with Gulick that it’s not yet time to toss out the condoms.
While prevention may be icing on the cake, the most compelling reason for starting ART early would be that it improves the health of people with HIV. HTPN 052 showed that this was the case for people with mid-range CD4 counts. A randomized clinical trial looking at when to start treatment for people with high CD4 counts—like the ongoing START Study—will require thousands of participants and take years. But in the meantime, Cohen said, U.S. guidelines recommending ART for everyone diagnosed with HIV are “almost certainly right.”
In his talk on HIV, aging and inflammation, Steven Deeks from UCSF offered evidence that early treatment may help ameliorate the excess immune activation and inflammation that contribute to non-AIDS conditions such as cardiovascular disease and cancer, which are occurring at an earlier age among HIV-positive people.
Now that the virus itself can be controlled, the field of HIV medicine is shifting toward management of chronic age-related conditions—especially in places like San Francisco where more than half of people with HIV are age 50 or older. “I give people ART and then I’m no longer an HIV doc,” Deeks said. While there’s probably no magic bullet for preventing age-related complications, healthy diet and exercise are key. “We can’t wait until [HIV-positive people] are old and frail to do something about it,” he added. “The goal is not surviving as long as possible, it’s staying healthy.”
ART and HIV Management
Numerous studies presented at IDWeek looked at specific aspects of HIV management. Here are just a few of the highlights:
- Katie Mollan, also from the University of North Carolina (abstract 670), reported that people with HIV who took efavirenz (Sustiva) were more than twice as likely to have suicidal thoughts or to attempt or succeed in committing suicide than those taking other antiretrovirals. The total number of “suicidality” events was low, however—8.08 vs 3.66 per 1,000 person years—and having a history of psychiatric problems was the biggest risk factor.
- Kamla Sanasi from the University of South Carolina and colleagues (abstract 673) found that HIV-positive people with stable viral suppression who had their viral load and CD4 count monitored every six months were no more likely to experience viral failure rebound or to change their ART regimen than those monitored every four months. At their clinic—which sees about 2,000 patients—reducing monitoring from three to two visits per year would save more than $787,000 annually.
- Asher Schranz from New York University (abstract 77) reported that HIV-positive people treated at community clinics—who were more often low-income or uninsured—were more likely to continue receiving care than those treated at hospital clinics (85% vs 82%). Both groups were equally likely to receive ART, but those treated at hospitals had a better chance of maintaining viral suppression (71% vs 76%). Community clinics may have the advantage of targeted care for specific populations, while hospitals may offer more specialty care and better management of comorbidities.
- Jennifer Edelman from Yale (abstract 76) and colleagues found that people with HIV often use multiple drugs for various conditions, known as “polypharmacy.” The most commonly used non-antiretroviral medications in a study of U.S. veterans included lipid-lowering drugs, blood pressure medications, antidepressants, non-opioid painkillers, and diabetes drugs. Using multiple medications was associated with a higher risk of death for both HIV-positive and HIV-negative patients.
- In a related study, Elizabeth Neuner and colleagues from the Cleveland Clinic (abstract 176) found that a multidisciplinary intervention including pharmacy education, an improved electronic order entry system, and daily medication reviews by an infectious disease specialist significantly reduced the number of medical errors (from 50% to 32% of all admissions) and increased the likelihood that errors would be resolved (from 36% to 74%).
- Finally, Michael Silverberg and colleagues from Kaiser Permanente (abstract 75) reported that people with HIV had twice the mortality of HIV-negative individuals of the same age after hospitalization for acute coronary syndrome (which includes heart attacks and unstable angina). But the excess risk disappeared for people on ART with high CD4 counts, supporting the recommendations for earlier treatment.
Looking to the Future
Looking toward the future of HIV care, Michael Saag from the University of Alabama gave an overview of the Affordable Care Act and what it means for people with HIV. On the upside, many more people are expected to get coverage, either through expanded Medicaid or through new insurance exchanges. On the downside, some of the states with the most low-income HIV-positive people are those that have refused to expand their Medicaid programs.
Ideally, Saag said, shifting more direct medical care to Medicaid would allow Ryan White Care Act funds to be used for public health efforts such as expanded HIV testing and linkage to and retention in care. He proposed that medical clinics could partner with community-based organizations to offer services like case management and substance abuse treatment that Medicaid does not cover.
Saag stressed the importance of HIV doctors signing up as health plan primary care providers so patients will have a choice of HIV-knowledgeable clinicians (see the HIVMA website for more info). “Obamacare is not the answer, but it is a step on the road to something better,” he concluded. “Whether we like it or not, we need to know the law and participate on behalf of our patients.”
All fields of medicine must control costs, and generic drugs may be part of the solution. Veteran HIV clinician John Bartlett from Johns Hopkins discussed the forthcoming advent of generic antiretrovirals as widely used medications like efavirenz go off patent.
Bartlett expressed some skepticism about the ACA—calling it “socialized medicine run by capitalists”—as well as the U.S. guidelines calling for immediate ART for all. He noted that medications account for around 70% of the annual cost of HIV care, which generic drugs could reduce substantially.
In particular, the availability of generics will offer the option of using combinations of cheaper drugs instead of brand-name coformulations. “If you ask a patient whether he wants to take one pill or three, he’ll prefer one,” Bartlett said, “but what if you tell him taking three will save $6,000 and you’ll give him half?”
While improvements in HIV treatment have saved millions of lives and improved the quality of many more, prevention and a cure remain the ultimate goals.
Connie Celum from the University of Washington in Seattle, an investigator with large trials showing the efficacy of Truvada pre-exposure prophylaxis, presented an overview of the current state of biomedical prevention, one of the fastest-moving areas in the HIV field. In addition to his aging lecture, Deeks also gave an overview of HIV cure research (similar to a talk he gave he gave at a community forum earlier in the week).
“Treating your way out of an epidemic is almost possible,” Cohen said to conclude his lecture. “[Treatment as prevention] is important, but not a replacement for a vaccine or a cure.”
“The race to cure HIV is incredible right now,” he continued. “Even if investigators don’t cure AIDS, I’m quite sure they’ll change the approach to therapy forever. Now is not the time to talk about cutting back research funds, it’s time to redouble our investment.”
Liz Highleyman is a freelance medical writer and editor-in-chief of HIVandHepatitis.com.