News (Updated October
16, 2011)
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Daniel M. Keller, PhD
October 16, 2011 (
"The contemporary
challenge in HIV medicine is no longer to suppress the virus but actually to
maintain health of patients with HIV, and the major focus now and the dominating
reason for why people are still getting sick, even for those who are in care, is
the development of various co-morbidities," said Jens Lundgren, MD, DMSc,
professor in the Department of International Health, Immunology and Microbiology
at the University of Copenhagen, Denmark, director of the Copenhagen HIV Program
in Denmark, and chairman of the section on comorbidities of the guidelines
committee.
Fortunately, suppression
of HIV has become so effective that comorbid conditions are a real concern.
"HIV physicians are great in treating the virus but may not have the skill
set necessarily to deal with the prevention and treatment of the
co-morbidities," he noted. "We have involved experts in the fields of
the organ diseases, and therefore we believe that we are providing contemporary
guidance on that."
This focus on comorbid
conditions constitutes a major revision to the previous set of guidelines,
issued in 2009. The most recent set, version 6, is available at
www.europeanaidsclinicalsociety.org in English and several other languages.
Guidelines have been issued every 2 years at the biennial EACS conference.
Organization of Guidelines
The goal of the design of
the guidelines was to make them easy to use in routine clinical practice yet
comprehensive enough to address the patient as a whole. The guidelines are
organized in 4 sections:
Assessment of HIV-infected
patients at initial and subsequent visits;
Antiretroviral treatment
of HIV-infected patients;
Prevention and management
of noninfectious comorbid conditions with HIV; and
Clinical management and
treatment of chronic hepatitis B and C co-infection in HIV-infected adults.
Dr. Lundgren advised that
clinicians cannot use the same approach in treating comorbid conditions with HIV
as they do in the general population since HIV affects the risk for diseases in
various organs. "Equally, the medicines that you use to prevent and treat
these comorbidities interact with the drugs that we are using to treat the HIV
virus itself," he said at a news conference that Medscape Medical News
attended. "Therefore, it's quite important that when you care for people
with HIV that you have a comprehensive look at the person rather than just
focusing on the virus itself."
Beginning on page 10 of
the printed English version is a 6-page chart delineating a standard of care for
the assessment of HIV-infected patients at initial and subsequent visits through
interviews and laboratory tests. It deals with history (including medical,
psychosocial, and sexual and reproductive health), HIV disease, co-infections,
and noninfectious comorbid conditions.
A Web version in
development (links at www.europeanaidsclinicalsociety.org) will expand on the
print versions with additional information, tables, and links to resources on
lifestyle interventions, antidepressant drugs, renal tests, drug dosage
adjustments for renal impairment, other drugs and dosing with comorbid
conditions, drug dependency and addiction, management of metabolic disorders,
and activities of daily living.
Specific Features
The guidelines help
clinicians assess patients' readiness to initiate treatment with antiretroviral
drugs based on behaviors, cognitive problems, level of health literacy, health
insurance and access to drugs, and social support and disclosure. Then they make
3 levels of recommendation for initiating therapy according to the CD4 cell
count and the presence of various health conditions and comorbid conditions. The
recommendations are:
R: recommended
C: consider (some level of
uncertainty; more evidence from randomized trials is needed)
D: deferral of therapy
Significant attention is
given to adverse effects and drug-drug interactions.
Noninfectious Comorbid
Conditions in HIV
Tables or flow charts lead
clinicians through cancer screening, including for hepatocellular carcinoma in
the presence of cirrhosis; prevention of cardiovascular disease; hypertension
diagnosis and management; and treatment of diabetes, depression, bone, and
kidney disease.
Dr. Lundgren said all
patients should be scored for their risk for cardiovascular disease with an
HIV-specific risk equation, and one should consider modifying antiretroviral
therapy if the 10-year risk for a cardiovascular event is greater than 20%.
An update from the 2009
guidelines concerns lipid-lowering therapy, which is now recommended only if the
10-year risk is greater than 20% in primary prevention.
Another modification from
the 2009 version concerns blood pressure. "For people diagnosed with
hypertension with an age of less than 55 [years], the recommended initial
medication is an [angiotensin-converting enzyme] inhibitor whereas for people
who are above 55 or black patients of any age, the recommended first choice is a
calcium-channel blocker," Dr. Lundgren said. If single-agent therapy is not
sufficiently effective, a diuretic may be added. "This is a fairly
substantial change in recommendations for management of hypertension compared to
the 2009 [guidelines], and again, this is done out of the advice of colleagues
expert in the hypertension field," he said.
He noted that there has
been much discussion of what is the appropriate cut-off for the diagnosis of
impaired glucose tolerance, and the guidelines panel agreed on a fasting plasma
glucose level of 5.7 to 6.9 mmol/L (110 to 125 mg/dL), as recommended by the
World Health Organization and the International Diabetes Federation in 2005.
For first-line treatment,
the panel recommends first considering use of metformin or possibly
sulfonylureas, depending on specific patient characteristics. HIV-specific
factors can affect glycated hemoglobin values, so plasma glucose may be a better
indicator of the need for treatment. As good practice would dictate, clinicians
are urged to screen their diabetic patients for nephropathy, retinopathy, and
polyneuropathy.
Screening for kidney
disease is an evolving area, but Dr. Lundgren advised that "it is
absolutely clear now that we do need HIV clinics to start to screen the urine
for protein in order for you to be able to calculate the urine protein-to-creatinine
ratio because this has major impact not only on the progression of the kidney
disease but also on extra-renal complications for people with impairment of
renal function... so we can no longer just take blood from patients."
It is also important to
determine the estimated glomerular filtration rate, and there are various
standard methods. A table in the guidelines has been simplified from the
previous version for managing individual patients according to estimated
glomerular filtration rate and the urinary protein-to-creatinine ratio.
The antiretroviral drugs
tenofovir, indinavir, and atazanavir can be nephrotoxic, and a table presents
management strategies in this still-evolving area. "The question at the
moment is whether there is an immediate hit from using these drugs or whether
there is a gradual deterioration of renal function," Dr. Lundgren said.
A section on vaccination
lists rationales, dosing, and schedules in the setting of HIV infection, as well
as the use of live vs attenuated vaccines, which ones to combine or not, and
assessing effectiveness using antibody titers.
Recreation and Enjoyment
of Life
The guidelines help
clinicians make recommendations to their patients who want to travel. A table
provides general precautions, advice on antiretroviral therapy, and the need for
extra awareness because of their heightened susceptibility to food and
insect-borne diseases. It also refers people to www.hivtravel.org for advice on
travel restrictions.
A new section gives
clinicians systematic guidance on assessing and treating sexual dysfunction in
people living with HIV, including taking a general sexual history, determining
the nature of the complaint, identifying the cause of the problem, and making
the appropriate referral.
EACS sponsored development
of the guidelines and did not receive any industry support. Dr. Lundgren has
disclosed no relevant financial relationships. He chaired the comorbidity
section on the guidelines committee.
13th European AIDS
Conference,
Scientists at
Researchers found
"prominent changes" of the functional connectivity in the visual
networks of the HIV patients.
Diminished cognitive
functions affect around 50 per cent of sufferers and can impair a range of
sensory functions such as memory, attention and verbal capabilities.
"These findings
indicate that changes in brain function are occurring very early in HIV
infection and subclinical alterations in functional connectivity may reflect
vulnerability to cognitive decline," said Ann Ragin, the principal
investigator from
According to the Aids
charity Avert, 86,500 people were living with the disease in the
Oct 11 2011
The Medicines Patent Pool
said on Tuesday the agreement would allow Aurobindo to make a range of AIDS
drugs licensed to the pool by Gilead Sciences, the leading maker of HIV drugs,
in July.
Aurobindo has also elected
to take advantage of a key provision in the pool's licenses in order to sell one
drug, tenofovir, to a wide range of countries without paying royalties. These
could include several middle-income countries such as
Around 33 million people
worldwide have the human immunodeficiency virus (HIV) that causes AIDS. Most
live in Africa and
The Medicines Patent Pool,
launched by the UNITAID health financing system that is funded by a tax on
airline tickets, aims to address the problem by creating a system for patent
holders to license technology to makers of cheap generics.
(Reporting by Ben
Hirschler; Editing by David Holmes)
By Kate Kelland
LONDON Oct 12 , 2011
(Reuters) - Life expectancy for people in Britain who have HIV rose by 15 years
between 1996 and 2008, thanks largely earlier diagnosis and treatment with
better, less toxic drugs, scientists said on Wednesday.
While life expectancy for
HIV patients is still lower than in the general population, dramatic progress in
reducing side effects from drugs, offering them as combination therapies and
starting treatment earlier have helped turn HIV into a chronic disease with a
good prognosis, the researchers said.
In a study published in
the British Medical Journal, the researchers added that the average lifespan of
HIV positive patients should increase further with guidelines recommending they
start treatment even earlier with modern, improved drugs.
"These results are
very reassuring news for current patients and will be used to counsel those
recently found to be HIV-positive," said Mark Gompels of
Around 34 million people
globally have the human immunodeficiency virus (HIV) that causes AIDS, and the
vast majority of them live in sub-Saharan
Access to screening,
diagnosis and early treatment with HIV drugs is limited in many poorer nations,
but in wealthy countries like
Gompels worked with
Margaret May of Bristol University and used data from the UK Collaborative HIV
Cohort study, which in 2001 began collating routine data on HIV positive people
who had been attending some of
They looked at patients
aged 20 and over who started treatment with at least three HIV drugs between
1996 and 2008.
Their analysis showed that
life expectancy for an average 20-year-old infected with HIV increased from 30
years to almost 46 between the periods 1996 to 1999 and 2006 to 2008.
"We should expect
further improvements for patients starting antiretroviral therapy now with
improved modern drugs and new guidelines recommending earlier treatment,"
May said in a statement about the work.
The findings also showed
that life expectancy for women treated for HIV in
During the period 1996 to
2008, life expectancy was 40 years for male patients and 50 years for female
patients, compared with 58 years for men and nearly 62 years for women in the
general
In a comment on the
findings, Elena Losina, a senior scientist at the Boston Brigham and Women's
Hospital in the
"In turn this should
increase rates of routine HIV screening, with timely linkage to care and
uninterrupted treatment," she said. "As these factors improve, the
full benefits of treatment for all HIV infected people can be realised."
(Editing by Rosalind Russell)