October 15, 2012
We tell our patients that HIV has become like other chronic diseases -- and, largely, we believe it. These patients are aging along with us, and clinic visits have become more like routine checkups with continued praise for undetectable viral loads and admonishments to shed pounds. Even our scientific literature has become more mundane; it is less preoccupied with finding silver bullets than with developing strategies to help people live well with their virus into their golden years.
There are exceptions, of course. Developers of an HIV vaccine and developers of a cure are laboring on breakthroughs, and prevention research has yielded interesting, if not provocative, discoveries. But with a cornucopia of antiretrovirals, superb efforts to monitor care delivery, and a deep understanding of who is at risk for HIV infection, we know what we need to do until such dreams become realities.
Below are examples of recent reports that help us stay the course until we have a vaccine and cure. They include studies that take stock of our successes, flash caution about our medications, and point to lurking problems that challenge the prevention and treatment of HIV.
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Keri N. Althoff et al. Ann Intern Med 2012;157:325-335. Read the abstract.
The most compelling reason to include this article in our latest JournalView installment will be best appreciated by fans of A. A. Milne, Shel Silverstein and Mary GrandPré. Each of these artists gave us a common visual reference for the story being told, whether it was about a paunchy bear with a honey addiction, a flatulent ogre with an attitude or a resilient young wizard with a flashy forehead scar. It is difficult to imagine these books without the drawings that intermittently grace their pages.
Similarly, this article -- the latest "how are we doing?" from the NA-ACCORD cohort of HIV-infected patients in care -- is pretty cool, but it is the pictures that make it special. There is the map, all in shades of blue (no red states!), showing the proportion of people with HIV infection who are engaged in medical care in different U.S. states. (You go, Washington, Louisiana and Tennessee!) Then, there are the bar graphs of changes in antiretroviral therapy use over time (I swoon for horizontal bar graphs, don't you?), not to mention a multilayered, 4-D graphic of temporal trends in viral suppression. Marvelous.
We could show these images here, but our lawyers won't let us. Happily, there are also some words in the study worth looking at. The short version goes something like this:
These data will hopefully be mined for more gems. For example, other studies have shown disparities in HIV care outcomes, such as in HAART prescriptions and viral suppression, by race in the U.S. Similarly, retention in care is a challenge and understanding who is at greatest risk of dropping out can lead to interventions (see below regarding the possible role of pain). These should be easy to examine in this cohort.
Meanwhile, I can't help but feel great after reading an NA-ACCORD article. The cohort study is one of the best at showing how the epidemic is evolving and what we are collectively accomplishing. And there are the pretty pictures.
Jessica S. Merlin et al. J Acquir Immune Defic Syndr 2012;61:164-170. Read the abstract.
Once we started asking our patients to point out which bald-headed face represented their level of discomfort -- choices ranged from the euphoric to the tear-shedding despondent -- we came to feel their pain. Now practically a vital sign, pain scales are supposed to help us discover and address suffering.
Of course, the validity of such scales in those with HIV is not clear. We all have had patients who respond that they have 10 out of 10 pain (that is the worst pain imaginable), but are smiling and moving about without any outward display of distress.
But pain is complex, and it can be life-sapping. Patients living with HIV may be more likely to experience pain as a consequence of the virus and its therapies, as in the case of peripheral neuropathy, or due to comorbid conditions far removed from their infection.
A study conducted at the University of Alabama-Birmingham examined the prevalence of pain and its impact on clinic visits (especially no-shows), adherence to HIV medications and viral suppression. The study cohort included 1,521 patients (mean age 44 years; most were non-white, male, uninsured or publically insured; and 64% had a CD4+ cell count >350 cells/mm3). A third of the patients reported pain (more than 70% recorded moderate or extreme pain at the initial point of data collection), a quarter had mood disorders and 10% reported substance abuse.
In multivariate modeling, the presence of pain increased the odds of a subsequent clinic no-show, but only in those without substance abuse (OR 1.5; 95% CI, 1.1-1.9). Pain actually reduced the odds of no-shows for those with substance abuse (OR 0.5; 95% CI, 0.2- 0.9, P for interaction = 0.0022). Similarly, substance abuse increased the odds of a no-show visit only in those without pain, while for patients with pain, substance abuse had no effect on the odds of a no-show visit.
Other factors that were associated with a no-show were being a non-white female, a non-white male or a white female; a lack of private insurance; and a CD4+ count above 200 cells/mm3. Giving credence to the whole age-equals-wisdom thing, increasing age was inversely associated with not showing up for a visit. Pain was not correlated with antiretroviral adherence or with virologic outcomes.
These results are interesting, if not somewhat validating of clinical experience. Pain among those with substance abuse seemed to be a motivator for medical visit adherence. (OK, most of you are probably thinking, "Duh," and perhaps this is explained by the fact that pain medications such as opioids are prescribed during clinic visits -- or at least the patients hope they will be.) For those without substance abuse, the link between pain and missing visits is not as intuitive. Perhaps these folks were too sick to come in or were frustrated that their pain was not being adequately addressed.
Given the importance of retention in care to maintaining the benefits of treatment (in terms of personal well-being and transmissibility), the finding that better pain management may keep people in care is significant. As the needs of our patients expand, we HIV providers have to be many things to many people. Adding "pain specialist" to that list can be tricky, but may help our patients in more ways than we expected.
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