This Week in HIV Research: A Test of Resistance

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As HIV treatment continues to improve with each passing year, it's wise to pause every now and then and ask ourselves: Does our approach to HIV clinical care still make sense? Or do aspects of care need to evolve alongside our medications and our growing knowledge? Those questions frame our top story in this week's spotlight on recently published HIV-related research, and they echo among our other stories as well, as new study findings force us to ask ourselves how we can better prevent and treat HIV in the U.S. Findings such as:

  • The arguably negligible value of baseline genotype testing for people newly diagnosed with HIV.
  • The association of severe insomnia with cardiovascular disease among people with HIV.
  • A greater prevalence of cardiovascular risk among older women with HIV than older men with HIV.
  • An excruciatingly slow apparent improvement in racial disparities among women diagnosed with HIV.

Join us in reading more about each of these findings -- and in questioning how we can best address their implications. To beat HIV, you have to follow the science!

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Routine Genotype Testing at HIV Diagnosis Not Cost-Effective in U.S., Model Suggests

Given that official U.S. HIV treatment guidelines so strongly recommend first-line antiretroviral therapy regimens that feature integrase inhibitors, baseline HIV genotyping at diagnosis is no longer cost-effective, a modeling study published in Clinical Infectious Diseases concluded.

Genotype testing, which determines whether a person's particular strain of HIV is already resistant to specific antiretroviral medications, would only alter drug selection for a small subset of people, the study determined -- and would add less than one quality-adjusted life day per person on average. Given that the test costs $500 per person, the researchers' model predicted an incremental cost-effectiveness ratio (ICER) of $420,000 per quality-adjusted life year (QALY). That's compared to a 2005 analysis, conducted prior to the first U.S. approval of an HIV integrase inhibitor, which found an ICER of $23,900 per QALY for baseline genotyping.

In the U.S., an ICER below $50,000 is commonly considered cost-effective. Given the comparatively limited medication choices in 2005, routine genotyping prevented enough treatment failures to be considered cost-effective at the time. However, integrase inhibitors are the vanguard of a generation of newer drugs with far higher barriers to resistance; thus, such testing no longer prevents enough virologic failures to be cost-effective, authors of the current study argue.

The authors called for reconsidering the current U.S. recommendation of baseline genotyping at diagnosis. However, they cautioned that their model applies only to current treatment recommendations in the U.S. and may not apply to future therapies or in countries where integrase inhibitor-based therapy is not considered an accessible preferred option.

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Severe Insomnia Associated With Cardiovascular Disease

U.S. veterans living with HIV who reported highly bothersome insomnia had a significantly higher risk of cardiovascular disease (CVD) than veterans without such symptoms, a study published in Journal of Acquired Immune Deficiency Syndrome found.

Researchers analyzed data on 3,108 participants, 97% of whom were men, in the Veterans Aging Cohort Study Survey Cohort. Median follow-up time was 10.8 years. At baseline, 445 (14.3%) reported being bothered "a lot" by insomnia symptoms. That group accounted for 10.8% of the 267 CVD cases. The adjusted hazard ratio for those reporting highly bothersome insomnia compared to those reporting no trouble falling asleep was 1.64; that ratio fell slightly to 1.51 when further adjusted for depression.

Study authors called for additional research that may lead to insomnia interventions in CVD prevention programs for people living with HIV. However, the association between sleeping difficulties and heart problems is not unique to those living with HIV. The American College of Cardiology reported in 2016 that meta analyses had found a strong association between poor sleep and coronary heart disease, myocardial infarction, and stroke. The report noted the effectiveness of cognitive behavioral interventions for combatting insomnia and included tips for better sleep that clinicians can share with their patients.

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Cardiovascular Risks More Prevalent in Older Women Than Older Men

In people aged ≥ 50 years who are living with HIV, certain cardiovascular comorbid conditions were more common among women than men, a U.S. study published in Clinical Infectious Diseases showed.

Specifically, in participants aged 50 to 64 years, women's adjusted prevalence difference was 8.4 for obesity, 3.9 for hypertension, and 9.9 for high total cholesterol, compared to men. In the 65+ age group, women were more likely to have diabetes mellitus and high cholesterol than men.

Ninety percent of the 7,436 study participants were 50 to 64 years old, and 75% were men. While everyone was in HIV care, 50- to 64-year-old women were less likely to have been prescribed antiretroviral therapy or be virally suppressed than participants in any of the other groups.

Study authors cautioned that missing data and modest response rates may have influenced results but noted their use of weighting procedures to adjust for nonresponse bias. They called for more research among older people living with HIV to develop custom interventions for better cardiovascular outcomes in that population.

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Racial Disparities in Seroconversions Persist Among Women

While HIV rates among African-American women declined modestly between 2010 and 2016, significant racial disparities persist, the U.S. Centers for Disease Control and Prevention (CDC) reported in Morbidity and Mortality Weekly Report.

Data include adolescents and women age 13 and older. In 2016, 60% of new seroconversions in women were among African Americans, who make up 13% of U.S. women. In African Americans, estimated HIV incidence fell from 32.5 per 100,000 women in 2010 to 24.4 per 100,000 in 2016, while in whites it was 1.6 per 100,000 women in both years.

If infection rates were the same between the two races, 93% of HIV acquisitions among African American women would have been avoided in 2016, the CDC estimated. Study authors noted the influence of social and structural determinants of health on seroconversion rates, and the need to reduce racial disparities in order to achieve the U.S. goal of eradicating the HIV epidemic by 2030.

Since most African-American women acquire the virus through heterosexual sex, men who have sex with women should be included in HIV prevention strategies, the study authors recommended.