This Week in HIV Research: Every Prescription Can Use a Good Steward
It's become increasingly clear in recent years that, as with so many things, quality HIV care truly takes a village. Comorbid conditions, polypharmacy, mental health needs, socioeconomic hurdles -- all of these factors and more make effective HIV management a multidisciplinary challenge. Our lead study this week homes in on one aspect of this reality: the potential value of antiretroviral stewardship in general health care settings, particularly inpatient care.
Of course, we've got three other clinically relevant research findings to recap for you this week, all with notable implications for HIV patient management. Here's what's on tap for today's tour of recently published, peer-reviewed HIV science:
- Implementation of an HIV antiretroviral stewardship plan in hospitals can potentially save a good chunk of money -- and may save patient lives as well.
- It's common for people to pause or stop pre-exposure prophylaxis (PrEP) after they've started it -- and it's a lot more common depending on a person's race, gender, or age.
- Higher rates of cardiovascular complications among people with HIV may be at least partly due to a greater incidence of atrial fibrillation.
- Cytopenias, including anemia and neutropenia, are more common among people living with HIV, even in the face of viral suppression.
Let's give each of these studies a closer gander. To beat HIV, you have to follow the science!
Antiretroviral Stewardship Prevents Inpatient HIV Medication Errors
An antiretroviral stewardship team can prevent medication errors when people living with HIV (PLWH) are admitted to a hospital, a single-site study published in Open Forum Infectious Diseases found.
Researchers analyzed 567 admissions of PLWH to Temple University Hospital in Philadelphia, Pennsylvania, in which an antiretroviral was ordered between July 2017 and June 2018. The stewardship team intervened 336 times to correct drug regimens or dosages, request lab tests, prevent drug interactions, or provide advice when the antiretrovirals a patient was taking weren’t on the hospital formulary.
The most common problem corrected was drug interactions (152 interventions), especially coadministration of polyvalent cation supplements and integrase strand transfer inhibitors (INSTI), or of acid-suppressing medication and rilpivirine or atazanavir. The supplements must be given at a different time than the INSTI, and proton pump inhibitors, a class of acid reducers, should not be used with certain antiretrovirals.
The study focused on potential cost savings (calculated to be an average of roughly $813 per intervention, with a total of $263,428 saved during the study period), but preventing HIV medication errors may also avoid HIV-related disease or even death, study authors noted. “Recognizing risk factors such as multitablet inpatient regimens, admission to the intensive care unit, care provided by a surgery service, and increased number of days reviewed may help prioritize HIV-infected patients at higher risk for error,” they concluded.
African Americans, Transgender Women More Likely to Stop PrEP
Eighty-four of 348 people (24%) who received pre-exposure prophylaxis at public San Francisco primary care clinics between 2012 and 2017 ultimately stopped taking PrEP for at least 90 days or discontinued it altogether, researchers reported in AIDS. But the most notable findings of the study may be the demographic differences seen among people who interrupted PrEP.
Forty-six percent of these 84 participants were lost to follow up and 12% stopped PrEP due to medication cost. African Americans were more likely to discontinue PrEP than whites (adjusted hazard ratio 1.87), as were transgender women who have sex with men compared to men who have sex with men (aHR = 1.94). Conversely, older people were more likely to continue PrEP (aHR = 0.89) compared to younger participants.
Medicaid or Medicare insurance was common, and 14% of participants had no medical insurance. Four of the 14 clinics started PrEP support through panel management or patient navigators, but such support was not associated with lower rates of stopping PrEP.
“Even after adjusting for important individual factors in our analysis, disparities in PrEP discontinuations persist indicating social and structural barriers must [be] better addressed to support Black patients continuing PrEP,” study authors concluded.
PLWH at Higher Risk of Atrial Fibrillation
In a large California study, living with HIV was associated with a significantly higher risk of atrial fibrillation (AFib) than was being HIV negative, researchers reported in Journal of the American College of Cardiology. AFib is a leading cause of irregular heartbeats and stroke.
The study included more than 17 million people, 18,242 of whom were living with HIV. During the study period (2005-2011), 625,167 people were newly diagnosed with AFib. The incidence rate for AFib was 18.2 per 1,000 person-years among PLWH compared to 8.9 per 1,000 in HIV-negative people.
While PLWH had more cardiovascular risk factors, their risk for AFib remained higher (hazard ratio: 1.46) even after adjusting for a variety of these factors. Since AFib may be asymptomatic, study authors concluded, “These data provide compelling evidence that those with HIV should indeed be considered at high risk for the disease.” They also recommended further research into the underlying mechanisms for this association, as well as the effect of antiretroviral therapy on AFib risk.
Suppressed or Not, HIV Is Risk Factor for Cytopenias
People living with HIV are at greater risk for anemia, neutropenia, and thrombocytopenia than the general population, even when they are virally suppressed, a study published in The Journal of Infectious Diseases showed.
Researchers analyzed blood samples from 796 PLWH with undetectable viral loads and 2,388 matched HIV-negative controls; participants came from two parent studies in Copenhagen, Denmark. PLWH had significantly higher rates of anemia (6.9% vs. 3.4%), thrombocytopenia (5.5% vs. 2.7%) and neutropenia (1.3% vs. 0.2%) than controls.
Previous studies had reported significantly higher anemia rates among PLWH, but these were conducted among populations with confounding risk factors, such as malaria or hepatitis, study authors explained. “Although cytopenias are relatively rare, HIV remains a risk factor for cytopenias in the contemporary [combination antiretroviral therapy] era and requires ongoing attention and monitoring,” they concluded.
Of note, the researchers did not discover a similar relationship between HIV and lymphocytopenia. In fact, lymphocyte counts among PLWH were higher than among controls, possibly due to differences in the CD4/CD8 T-cell ratios between the two groups.