January 26, 2018
This week, we get another sobering reminder that HIV pre-exposure prophylaxis (PrEP) remains deeply underprescribed in many U.S. health care settings. We also dip our toes into a triad of recent studies exploring markers and risks for serious non-AIDS events, including the role of inflammation, age and serum albumin.
To beat HIV, you have to follow the science!
Very few local health departments in North Carolina prescribe HIV PrEP or provide referrals for such services, a study published in Journal of Acquired Immune Deficiency Syndrome showed.
Two-thirds of the state's 85 health departments responded to a survey about PrEP practices at their facility. Two departments (4% of respondents) said they prescribed this biomedical HIV prevention method, and seven (12.5%) referred clients to external providers. Sixty-two percent of the 47 facilities who reported they do not provide PrEP referrals said there were no local providers to whom clients could be referred.
The reason most frequently cited for not prescribing PrEP was cost, followed by the perceived lack of a formal protocol. While clinical guidelines exist, personnel may not be aware of them, and guidance may need to be tailored to the constraints faced by health departments, study authors suggested.
Eleven of the facilities surveyed said they were considering or preparing to engage in PrEP activities. Staff training, the most requested PrEP resource in the survey, has been provided recently by the local AIDS Training and Education Center, authors added, and additional departments were working on implementing this prevention method.
People with suppressed viral loads and CD4+ counts ≥ 300 cells/mm3 experience life-threatening non-AIDS events associated with biomarkers of inflammation and coagulation much more frequently than serious AIDS-related and "traditional" non-AIDS events, such as cardiovascular disease and some cancers, a study published in Journal of Acquired Immune Deficiency Syndrome found.
The current cohort study followed 3,568 participants for a median of 4.3 years. During that time, 339 experienced a grade 4 (life-threatening) adverse event, and in 165 that event was related to chronic inflammation. Higher baseline levels of interleukin-6 (IL-6), a marker for systemic inflammation, and D-dimer, a marker for coagulation activity, were associated with a greater risk of developing a grade 4 event. Such an event, in turn, was associated with a greater risk of death.
Inflammatory conditions beyond cardiovascular disease, cancer and AIDS may need to be considered in future research, study authors said. They also noted that participants' median nadir CD4+ count of 210 cells/mm3 may have affected the results and called for further investigation in people with higher nadirs.
Older people living with HIV (PLWH) are at greater absolute risk of developing certain cancers compared to similarly aged people within the general population, a data analysis published in Clinical Infectious Diseases reported.
Researchers used information on 183,542 people 50 years of age or older, among whom there were 10,371 cancers. Comparing PLWH to the general population, standardized incidence ratios (SIRs) were significantly higher among PLWH for most cancers, from 103.34 for Kaposi's Sarcoma (KS) to 1.66 for oral cavity/pharyngeal cancer. The exception were breast, prostate and colon cancers, for which the SIR was below 1.
Cancer risk for KS, Hodgkin lymphoma, lung and breast cancer was especially high within five years of an HIV diagnosis. Study authors noted the increased risk may be due more immune suppression in the initial period of untreated PLWH. Further, increased medical surveillance after diagnoses might detect cancers more regularly, they theorized, and lifestyle habits linked to cancer risk are more prevalent among newly-diagnosed PLWH. Stratification by age showed a decline in relative risk for most cancers among the older groups, but an increase in absolute risk for some non-AIDS-defining cancers as people aged. Study authors concluded that older PLWH's cancer risk is not compounded by their greater risk due to serostatus. They added, however that the higher absolute risk shows a need for cancer screening and prevention in this group.
Higher baseline serum albumin levels were associated with a lower risk of serious non-AIDS events among people living with HIV, a data analysis published in The Journal of Infectious Diseases found.
Serum albumin may be a cost-effective marker in resource-limited settings, study authors suggested. They modeled information on 4,576 participants in the Strategic Timing of Antiretroviral Treatment (START) trial, all of whom had baseline CD4+ counts of > 500 cells/μL. As a related commentary pointed out, only 1.5% (71) of participants developed a serious non-AIDS event, which may limit the usefulness of the data to determine whether this marker can ascertain a specific individual's risk. However, relative risk for serious non-AIDS events and unscheduled hospitalizations was associated with albumin levels across a variety of models.
Study authors did acknowledge that causality cannot be inferred from the results and called for additional research to determine whether serum albumin levels can be used in prognostic or frailty indexes.
|Ignorance About PrEP Is Common Among Health Care Providers, Studies Suggest|
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