April 25, 2013
Cardiovascular disease is the most common cause of mortality in the U.S. It is thus, almost by definition, a major topic of concern for the HIV-positive people we count among our patients and clients -- many of whom are intimately associated with traditional cardiovascular risk factors, such as cigarette smoking, low physical fitness, hyperlipidemia and hypertension.
Yet when it comes to the incorporation of cardiovascular risk management into HIV care, we haven't seen much in the way of consistent or comprehensive guidance. As we accumulate more data regarding the intersection of HIV and cardiovascular disease, a clearer picture of the issue is developing. But that picture has yet to be properly framed for many of the health care professionals who actively treat people with HIV in the U.S.
For this episode of HIV Management Today, we called in an expert to paint -- and frame -- that picture for us. David Alain Wohl, M.D., is an associate professor of medicine in the Division of Infectious Diseases at the University of North Carolina (UNC), the site leader of the UNC AIDS Clinical Trials Unit at Chapel Hill and the director of the North Carolina AIDS Education and Training Center. He is a widely respected clinician-researcher who has extensively spoken and conducted research on cardiovascular complications in HIV-infected populations.
March 14, 2013
In the typical conversation about HIV patient care, mental health is rarely a major topic of discussion. We talk about antiretrovirals; we talk about viral loads and CD4+ cell counts; we talk about the vast constellation of HIV- and HIV treatment-related complications that can impact our patients' well-being and affect the success of their therapy. In other words, we talk a lot about our patients' physiological health. We don't talk near as much about their mental health.
But if any of us have illusions that a patient's psychological state plays anything less than a critical role in his or her HIV care, and that health care providers do not have the power to dramatically improve that state, then we're due for a little re-education. In this episode of HIV Management Today, we discuss the extent to which mental health is inextricably tied to clinical health in HIV care, and what simple steps providers can begin to take to make mental health a more prominent part of the care they provide.
In July 2012, the U.S. Food and Drug Administration (FDA) approved, for the first time, an antiretroviral drug for the prevention of HIV. To be specific, the FDA approved the fixed-dose combination pill tenofovir/emtricitabine (Truvada). The drug has existed for years as an HIV treatment option, but the FDA's action this past summer made it the first drug approved for HIV pre-exposure prophylaxis, or PrEP for short.
As we prepare for the introduction of PrEP into clinical settings throughout the U.S., there are understandably a huge number of questions. To address many of these questions and obtain guidance for health care professionals across the clinical spectrum on how to prepare for and adjust to the rollout of PrEP, I spoke by phone with Antonio E. Urbina, M.D., the associate medical director at St. Luke's and Roosevelt Hospital's Center for Comprehensive Care's West 17th Street Clinic in New York City. Prior to that, Urbina was, for many years, the medical director of education and training at St. Vincent's Comprehensive HIV Center.
HIV therapy is a rapidly changing field. One might hope that more than 30 years of intimate experience with a virus might leave us with a firm sense of precisely how to treat it. But HIV has largely eluded easy answers, and antiretroviral therapy continues to evolve dramatically almost from year to year.
As a result, seemingly simple questions -- such as "When do I start my patient on antiretroviral therapy?" -- don't have simple answers. In this interview, I was honored to discuss this most fundamental of HIV treatment questions, along with other related issues, with two of the world's leading HIV specialists: Joel Gallant, M.D., M.P.H., a professor of medicine and epidemiology at the Johns Hopkins University School of Medicine and the associate director of the Johns Hopkins AIDS Service; and Paul Sax, M.D., the clinical director of the HIV Program and the Division of Infectious Diseases at Brigham and Women's Hospital, as well as the editor-in-chief of Journal Watch HIV/AIDS Clinical Care.
Both men are currently members of the panel of experts that periodically revises the bible of HIV treatment in the U.S.: the Department of Health and Human Services (HHS) antiretroviral therapy guidelines for HIV-infected adults and adolescents.
Over the past few years, the HIV clinical realm has seen an increased focus on the constellation of events that are associated with cardiovascular disease. In many ways, our understanding of cardiovascular risk in HIV-infected patients is still in its infancy. There remains a fair amount of uncertainty not only regarding the HIV- or antiretroviral-specific factors that increase this risk, but also regarding the strategies to employ in an effort to prevent, assess or manage the dangers of cardiovascular disease in people with HIV. But there is a lot we do know, and that knowledge can help guide clinicians as they determine the best way forward.
To discuss these issues, we brought together two of the leading minds on cardiovascular disease and HIV for a frank conversation: Marshall Glesby, M.D., Ph.D., the associate chief of the Division of Infectious Diseases and the director of the Cornell HIV Clinical Trials Unit at Weill Cornell Medical College; and Jens Lundgren, M.D., the chief physician and director of the Copenhagen HIV Programme. Both are at the forefront of research efforts in this area.
For years now, it has been clear that HIV-positive people are especially prone to developing unusual increases of fat in specific parts of their bodies. What has been less clear is exactly what a person with this type of fat gain, known as lipohypertrophy, can do about it.
On Nov. 10, a new option was approved by the U.S. Food and Drug Administration (FDA). Its name is Egrifta, known generically as tesamorelin. It is the first drug approved specifically for use by HIV-positive people with lipohypertrophy. Egrifta doesn't treat all kinds of fat gain -- it focuses on reducing fat gain in the belly area -- but its approval is historic nonetheless.
Joining us are two of the top HIV clinician/researchers in the United States. Dr. Valerie Stone is an associate professor of medicine at Harvard Medical School and an HIV/AIDS clinician at Massachusetts General Hospital, where she was director of the Women's HIV/AIDS Program from 2002 to 2008. Dr. Kimberly Smith is associate professor of medicine in the Department of Infectious Diseases at Rush University Medical Center and an active investigator and chair of several studies in the AIDS Clinical Trials Group. In our short discussion they will summarize the top issues in managing the care of the HIV-infected woman.
Selecting an initial antiretroviral regimen for an HIV-infected patient may seem easier than it has ever been, but it has often been said that the management of HIV/AIDS is more of an art than a science. Although it may be tempting to simply prescribe a single pill and be done with it, there are many factors to take into consideration when choosing antiretroviral therapy, from coinfections and underlying diseases to the potential complications of adherence and HIV drug resistance. In this installment of HIV Management Today, we consult with some of the top clinical minds in HIV on some of the most important issues in HIV/AIDS clinical management.