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Top 10 HIV Clinical Developments of 2012

December 2012

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"The Hopkins 87%": Reduced Racial Disparities in HIV Outcomes

A review of:

Richard D. Moore, et al. Improvement in the Health of HIV-Infected Persons in Care: Reducing Disparities. Clin Infect Dis 2012;55(9):1242-51.

This was a year of percentages. We had "The 99% " and, infamously, "The 47%." In HIV, HPTN 052's findings of the level of protection afforded by treatment of the HIV-infected half of a serodiscordant couple led to the bandying about of "The 96%" at our conferences. I would like to add a new pithy, numeric stand-in to the lexicon, and that is "The Hopkins 87%."

This is the proportion of patients at Johns Hopkins' Baltimore-based HIV clinic that was receiving HIV therapy in 2010. That same year, the median plasma HIV RNA level across the 6,366 patients cared for at the clinic was less than 200 copies. Likewise, median CD4 cell counts were high -- at almost 500/mm3 by 2010, with slightly lower counts seen among injection drug users compared to MSM and among men compared to women.

Importantly, by the last year of the study, there were no differences by race or risk group in receipt of antiretrovirals or suppression of viremia. Opportunistic infections became virtually extinct by 1998, and there were no differences between groups seen in more recent years.

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Lastly, there was no significant difference in mortality among the groups. Life expectancy computed for the entire sample found that, for a 28-year-old HIV-infected patient in their care in 2009, remaining life expectancy was calculated to be 45.4 years (95% confidence interval, 39.6-51.3 years). That is, a 28-year-old patient -- regardless of race, gender or risk category -- could be expected to live to 73 years of age.

That 87% of individuals in this clinic -- patients with a generous share of challenges -- are receiving HIV therapy is remarkable. That the vast majority has an undetectable viral load is extraordinary; it is a testament to the potency and convenience of our antiretrovirals, but also to the strong system of support that has been created to assist people with HIV.

These results fly in the face of health disparity trends in the U.S., wherein African Americans and those with lower socioeconomic status having higher rates of morbidity and mortality. Although HIV disproportionately affects those same populations that are at risk for worse outcomes and could be expected to compound these disparities, this study finds the opposite.

So, why do populations vulnerable to disparities in health care outcomes fare better when it comes to HIV care? Two words: Big Government. While that term may be slung in a political scrap, in the case of HIV, it is public funding through the Ryan White Care Act that provides the primary care, supportive care and medications assistance that is critical to achieving the very outcomes studied by the Hopkins investigators.

HIV is a complex and expensive disease to manage, yet the results coming from Baltimore are mirrored in clinics across the U.S. precisely because we have a national safety net that sets up those with HIV for success rather than failure.

While the investigators tout their finding of little to no difference in HIV outcomes across populations, what they also discovered is how different HIV is from other serious conditions in achieving this degree of parity. This lesson should be Exhibit A when the Ryan White Care Act comes up for reauthorization and as we look at the ways in which the Affordable Care Act will be implemented.

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Reader Comments:

Comment by: Ashley (QMsiijnYJx) Thu., Jan. 10, 2013 at 10:18 am EST
the HIV virus is very fragile once it is oudtsie of the human body. when it is exposed to the air, it dies in about 2 hours. so, dried semen will only have dead HIV cells. you are safe.
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Comment by: Mani (UubwaSyASLWZnBAlN) Thu., Jan. 10, 2013 at 9:29 am EST
I've talked to both my patrens about it at differnt times. My mom thinks it nessasary. She knows that teens r going to have sex and they need to be educated.My dad thinks its better to be educated then to not know anythingI think sex-ed is needed for everyone. I never though my dad (the republican who was in the army) Would be so libral
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Comment by: harleymc Tue., Dec. 25, 2012 at 11:02 pm EST
I was very happy to read this article.
I'm someone who's been on combinations containing boosted PIs and suffer badly with them. When my current script runs out in a few days I'll be switching to TDF/FTC/rilpivirine + raltegravir (already on the raltegravir). It was reassurring to read of an improvement in outcomes.

It's one thing to have a fabulous viral load but when side effects are both vile and life threatening, a change sounds brilliant.
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Comment by: Anonymous Mon., Dec. 17, 2012 at 10:48 am EST
good message of hope
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Comment by: Sean (Dublin, Ireland) Fri., Dec. 14, 2012 at 6:38 am EST
Thanks for the section called "The Cure Agenda". If YOU are feeling optimistic, that makes me feel optimistic.

Happy Yule!
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Comment by: Patrick D (South Deerfield, MA) Thu., Dec. 13, 2012 at 3:56 pm EST
Dr. Wohl writes "In the past, I have played with the HIV therapies of patients doing well, and on more than a few occasions I have been burned," then describes some of the benefits that may come from switching from a more complex drug regime to a more simplified one. Dr. Wohl clearly has his patients best interests in mind, but I want to remind him that when a switch in meds fails (temporarily or permanently) for patients who had been doing well on an older regime, it isn't the doctor who gets burned, it's the patient. I have had occasion to remind my own doctors of this, when they seem to want to fiddle with a regime that is working perfectly well, with negligible side effects, for no other reason than to put their signature on my treatment.

It can indeed be a benefit to simplify a drug regime, especially for patients who have trouble taking their meds in the first place. But as I've reminded several doctors, for many HIV patients, HIV drugs are not the only drugs we're taking (and that's not taking supplements into account), so simplifying the HIV drug regime alone doesn't result in not taking other drugs at other times of the day, and thus may not be a strong reason for changing a regime that's working.
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