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HIV Meds Updates: Fast Takes - ATV & Rilpivirine / Rifabutin

ATV pediatric powder formulation

An oral powder formulation of atazanavir has been approved by the FDA for use in infants and children older than 3 months and weighing 10 to <25 kg. It must administered with ritonavir, and used in combination with other antiretrovirals. For infants, it may be mixed with formula (or other liquid) and given with an oral syringe or cup. For older infants and young children, it may be mixed with yogurt or applesauce.

Dosing recommendations and other information are available in the updated product label, available at Drugs@FDA.

Rilpivirine and rifabutin

Serum concentrations of rilpivirine are substantially reduced by rifabutin. New PK data indicate that increasing the dosage of rilpivirine will overcome this interaction. Thus, the manufacturer now recommends that rilpivirine should be dosed at 50 mg once daily for patients concurrently taking rifabutin (ie, two 25 mg tablets of rilpivirine or 1 Complera tablet + 25 mg of rilpivirine once daily), taken at the same time and with a meal.

Source: 
AETC National Resource Center
Publish Date: 
Friday, August 1, 2014
Author(s): 
Author: 

Drug Interactions: Integrase Inhibitors and Cations

Antacids, laxatives, mineral supplements, and other compounds that contain metal cations (eg, calcium, magnesium, aluminum, and iron) may decrease levels of integrase inhibitors if taken close in time to each other. Results of two studies help to assess the magnitude of this effect and assist in determining how to manage it.

A study in HIV-infected subjects on stable raltegravir (RAL)-containing ART examined the effects on RAL levels of 2 antacids, calcium carbonate antacid (Tums Ultra 1,000 mg, 3 tablets) and magnesium/aluminum hydroxide antacid (Mintox Maximum Strength, 20 mL).[1] Compared with administration of RAL alone:

  • Simultaneous administration of calcium carbonate antacid with RAL resulted in 32% reduction in C12hr and 55% reduction in AUC
  • Simultaneous administration of magnesium/aluminum with RAL resulted in 63% reduction in C12hr and 49% reduction in AUC
  • Administration of magnesium/aluminum either 2 hours before or 2 hours after RAL resulted in 57% reduction in C12hr and 51-30% reduction in AUC

A study in HIV-uninfected persons examined the effects of calcium (calcium carbonate 1,200 mg) and iron (ferrous fumarate 324 mg) supplements on dolutegravir (DTG) (50 mg once daily).[2] Compared with administration of DTG alone:

  • Administration of DTG and calcium together on an empty stomach resulted in approximately 40% decrease in DTG AUC and C24hr
  • Administration of DTG and iron together on an empty stomach resulted in approximately 55% decrease in DTG AUC and C24hr
  • Administration of DTG with either calcium or iron together with food, and administration of either calcium or iron 2 hours after DTG did not reduce DTG concentrations

Based on these and other data, the prescribing information for the integrase inhibitors includes dosing recommendations for their use with polyvalent cations:

  • RAL:
    • Do not administer RAL and magnesium/aluminum hydroxide antacids simultaneously or within 2 hours of each other.
    • No dosing separation is necessary when coadministering RAL and calcium carbonate antacids.
  • DTG:
    • DTG should be administered at least 2 hours before or at least 6 hours after medications containing polyvalent cations, but DTG can be taken together with supplements containing calcium or iron if they are also taken with food.[3]
  • Elvitegravir:
    • Separate elvitegravir/cobicistat/emtricitabine/tenofovir (Stribild) and antacid administration by at least 2 hours.

References

  1. Isentress prescribing information and info from manufacturer. Merck & Co. April 2014.
  2. Song I, Borland J, Arya N, et al. The effect of calcium and iron supplements on the pharmacokinetics of dolutegravir in healthy subjects. In: Program and abstracts of the 15th International Workshop on Clinical Pharmacology of HIV and Hepatitis Therapy; May 19-21, 2014; Washington, DC. Abstract P13.
  3. Tivicay Prescribing Information. ViiV Healthcare. May 2014.
Source: 
AETC National Resource Center
Publish Date: 
Friday, August 1, 2014
Author(s): 
Author: 

Efavirenz Updates: Bone Mineral Density & Suicidality

Efavirenz and Bone Mineral Density

Persons with HIV infection have a number of risk factors for decreased bone mineral density (BMD), related not just to effects of HIV or resulting illness but also to ART. For example, BMD decreases by as much as 5-6% after initiation of ART, and certain ARVs (eg, tenofovir, protease inhibitors) cause greater losses over time than do others. It also is becoming clearer that vitamin D deficiency or insufficiency is common among HIV-infected persons, and that efavirenz can further lower levels of vitamin D.

A recent study evaluated the effects of vitamin D + calcium supplementation on bone metabolism in ARV-naive patients who were starting efavirenz/tenofovir/emtricitabine (Atripla). ACTG 5290 randomized 165 patients to receive vitamin D 4,000 IU daily + calcium 1,000 mg daily or to placebo. Subjects had 25-OH D levels ranging from 10 ng/mL to <75 ng/mL. They were relatively well matched for baseline criteria including age (36 and 31 in the two groups, respectively) race, BMI, HIV RNA, CD4 count, and estimated daily dietary vitamin D and calcium intake.

After 48 weeks, BMD decreased 50% less in the vitamin D + calcium group than in the placebo group:

  • Total hip-to-waist ratio: 1.46% vs 3.19%; p < .001
  • Lumbar spine: 1.41% vs 2.91%; p = .085

The 25-OH D levels rose significantly in the supplemented group but did not rise in the placebo group (p < .001 for difference between groups).

Echoing the BMD results, elevations in markers of bone turnover and parathyroid were attenuated in the vitamin D + calcium group (though there were no significant differences in changes in inflammatory markers).

Clinical Bottom Line

Importantly, this small study showed that supplementation with vitamin D + calcium attenuates bone loss in patients initiating EFV/TDF/FTC. Left unanswered by this study are many questions, including whether lower dosages of vitamin D would be effective, whether patients with normal vitamin D levels would benefit, whether supplementation would be effective in persons on different ARV regimens, and how long vitamin D should be continued; these questions merit further study.

Reference

  • Overton ET, Chan ES, Brown TT, et al. High-dose vitamin D and calcium attenuates bone loss with ART initiation: results from ACTG A5280. In: Programs and abstracts of the 2014 Conference on Retroviruses and Opportunistic Infections; March 3-6, 2014; Boston. Abstract 133.

Efavirenz and Suicidality

Efavirenz (EFV) commonly causes neuropsychiatric adverse effects in the early days and weeks after initiation, though these generally are mild to moderate in intensity and lessen with time. Many clinicians have been cautious about prescribing EFV for patients with serious psychiatric conditions, though serious adverse effects in these patients have not been well studied. A new analysis of suicidality among patients taking EFV helps characterize the risk of suicidality in persons on EFV-based regimens.

This is a combined analysis of data from 4 ACTG studies of initial treatment that included an EFV-containing arm (A5095, A5142, A5175, and A5202). 3241patients were randomized to regimens containing EFV (n = 3,241) or regimens without EFV (n = 2,091). The individual studies had somewhat different eligibility criteria (including differences in screening for suicidality) but the two groups were quite well matched at baseline for most factors including depression and use of antidepressant medications. Median follow-up was 96 weeks.

The main findings of the study are:

  • The incidence of suicidality, defined as suicidal ideation or attempted or completed suicide, was about twice as high in EFV-treated groups, and this held true in a variety of sensitivity analyses (other causes of death were present at essentially the same rate in the EFV and no-EFV groups).
  • Suicidality incidence (per 1,000 person-years): 8.08 in the EFV group, 3.66 in the no-EFV group (hazard ratio [HR]: 2.28, 95% confidence interval [CI]: 1.27 to 4.10; p = .006).
  • Attempted or completed suicide: 2.90 vs 1.22 in EFV and no-EFV groups, respectively (HR: 2.58, CI: 0.94 to 7.06; p = .065).
  • Completed suicides: 8 in the EFV group, 1 in the no-EFV group.
  • Other factors for increased hazard of suicidality were history of injection drug use (IDU), documented psychiatric history or recent psychoactive medication IDU, young age (on multivariate analysis).

Clinical Bottom Line

Although this study comes with several important limitations, including the facts that there was no standardized screening for suicidality and that some of the constituent studies were open label, its findings offer an important and sobering caution. It is important to screen carefully for risk of suicidality before prescribing EFV and to monitor regularly during treatment with EFV. This is particularly true for patients who have other risk factors for depression or suicidality.

Reference

  • Mollan KR, Smurzynski M, Eron JJ, et al. Association between efavirenz as initial therapy for HIV-1 infection and increased risk for suicidal ideation or attempted or completed suicide: an analysis of trial data. Ann Intern Med. 2014 Jul 1;161(1):1-10.
Source: 
AETC National Resource Center
Publish Date: 
Friday, August 1, 2014
Author(s): 
Author: 
Affiliation: 
AETC National Resource Center

HIV and Smoking - A Bad Combination

brianThis month CDC features an HIV-infected smoker as part of its highly successful anti-smoking campaign “Tips from Former Smokers," which tells the stories of real people harmed by smoking.

Smoking is among the most prevalent problems affecting HIV-infected patients. CDC estimates that in 2009, 42% of HIV-infected Americans in care smoked cigarettes [1] one of the highest rates reported for any subgroup.  For HIV-infected smokers, antiretroviral therapy shifts the risk of death dramatically away from HIV and towards smoking-related causes [2-4]. The hard-earned life-years gained from effective HIV treatment are squandered on cigarettes and other tobacco products at great personal and societal cost. In this context, smoking cessation should be a priority for HIV-infected persons; in addition to achieving effective antiretroviral therapy, smoking cessation could likely produce the greatest increase in quality and length of life. 

With the increased life expectancy for HIV-infected persons now afforded by remarkable advances in care, the need and opportunity to address smoking cessation have grown.  The current care model and work force for HIV infection are well suited to address smoking cessation. The frequency of care-related visits creates repeated opportunities to address smoking cessation. HIV specialists have experience administering behavioral interventions such as adherence and risk-reduction counseling, experience that is directly applicable to smoking cessation. For primary care practitioners, who in the changing healthcare landscape are expected to take on more of routine management of HIV infection, smoking cessation is already part of basic good clinical practice. Reassuringly, the pharmacologic interventions available for smoking cessation are generally safe to use with antiretrovirals.

There are multiple resources to help busy clinical practices help their patients quit, including specific handbooks for HIV-infected smokers: HIV & Tobacco Use, produced by the Mountain-Plains AETC (updated March 2014), and HIV Provider Smoking Cessation Handbook, produced by the Veterans Administration, and the Smoking Cessation chapter in the Guide for HIV/AIDS Clinical Care, produced by the Health Resources and Services Administration, HIV/AIDS Bureau and the AETC National Resource Center.

The fundamentals of what we know works in clinical settings are straightforward, and validated in numerous clinic-based trials over decades: 

  • Ensure that tobacco use status is routinely collected at clinic visits as a “vital sign”.
  • Provide brief advice to patients encouraging them to quit, ideally with that advice tailored to their circumstance.
  • Determine interest in quitting, and if interested provide assistance either in-office or by referral to community resources. Assistance can include brief counseling and cessation medications.  If in-house resources are not available or acceptable consider referring to 1-800-QUITNOW, which provides phone counseling in all 50 states as well as community referrals.  If not interested, explore reasons for lack of interest.  Regularly remind patients that smoking adds to the harm caused by HIV, undermining the benefits of antiretroviral treatment.
  • As with other key aspects of HIV treatment, track smoking or quit status at follow-up visits, and provide support based on patient characteristics.

 HIV can be managed. Smoking with HIV led to this.The bad news is that markedly high rates of smoking are a major cause of excess morbidity and mortality in our HIV-infected patients. The good news is that there are straightforward clinical interventions that can help our patients successfully quit if we practice them systematically in the context of delivering care for HIV.

References

  1. Mdodo R, Frazier E, Mattson C, Sutton M, T BJ, Skarbinski J. Cigarette smoking among HIV-infected adults: Medical Monitoring Project, US, 2009. In: 20th Conference on Retroviruses and Opportunistic Infections. Atlanta, GA, 2013.
  2. Lifson AR, Neuhaus J, Arribas JR, et al. Smoking-related health risks among persons with HIV in the Strategies for Management of Antiretroviral Therapy clinical trial. Am J Public Health 2010; 100(10): 1896-903.
  3. Helleberg M, Afzal S, Kronborg G, et al. Mortality attributable to smoking among HIV-1-infected individuals: a nationwide, population-based cohort study. Clin Infect Dis 2013; 56(5): 727-34.
  4. Helleberg M, May M, Sterne J, Obel N. Impact of smoking on life expectancy among HIV-infected individuals:tThe ART cohort collaboration. In: 21st Conference on Retroviruses and Opportunistic Infections. Boston, MA, 2014.

This story was summarized from an editorial that appeared in the July 2014 edition of the American Academy of HIV Medicine’s publication HIV Specialist.

Photo credit: HIV Specialist, July 2014 Volume 6 No. 2

Source: 
CDC Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, Sexual Transmitted Diseases and Tuberculosis Prevention
Publish Date: 
Tuesday, July 29, 2014
Author(s): 
Affiliation: 
U.S. Centers for Disease Control and Prevention

Inside the New England AETC HIV Consultation Preceptorship Program: 2014

The New England AIDS Education and Training Center (NEAETC) has provided opportunities for physicians and nurses to hone their HIV skills for over 27 years. The HIV epidemic now seems to take a backseat to other trending health related crises in the US; Hepatitis C and Opioid overdoses to name two and yet we continue to receive applications from those looking for a chance to learn HIV practice in some world class institutions of Infectious Disease (ID) care. This year we had a doctor with a special interest in functional medicine precept in an ID clinic at an urban hospital where primarily underserved persons with HIV are seen.  As described below, an aging HIV population presented both dilemmas and learning opportunities for this young physician.

Compliance issues due to recurrent family stressors are common – A 48 year old female with a CD4 count of fewer than 50 recently lost her brother in a shooting incident. Relationships are important for stability and long term care - A Haitian Creole speaking male comes in to be seen for his well controlled (22 years) AIDS diagnosis. His community nurse practitioner who has followed him all these years is about to retire. 

Pain issues are common and often psychosocial history makes patients appear more drug seeking than they are, or perhaps they have given up and just use street drugs to assuage pain – A Bisexual male comes in well controlled on meds with documented severe right hip osteoarthritis and bi-lateral avascular necrosis. Patient is having a problem staying clean from cocaine, runs out of his pain medications regularly and the surgeon refuses to operate on him until he is free from cocaine. 

There is a diversity of experience and creativity with which to explore findings- A 50 year old male presents for follow-up after a ceiling tile fell on his head. His HIV is stable and Viral Load (VL) is undetectable on Highly Active Antiretroviral Therapy (HAART).  A traumatic brain injury (TBI) patient may take weeks to months to recover.  An experienced mentor will not get locked into traditional, rote neurological exams but will demonstrate useful and creative ways to evaluate the patient and pull all of the information into context. This will lead to a plan that is most beneficial for the patient. Curiosity, experience, creativity and time combined together are vital to tease out the continuum of abnormalities. Occasionally our “fill in the blank” Electronic Medical Records (EMRs) forget this. It is the insight and experience of the preceptors that help to fill in the blanks for the learner.

Many patients come in asking for a “cancer check” perhaps because they are aging, and they have heard of cancers and HIV as a common connection.  There are no specific guidelines regarding cancer for the HIV population that are different than the HIV negative population save anal Pap smears and HPV testing and scoring.

Why does HIV HAART often cause hyper-triglyeridemia and or diabetes? Might it respond to a low fat diet and/or a low refined carbohydrate diet?  Finding a way to address the needs of people who have limited incomes, high stress and who use comfort food for relief is difficult. Providing a list of low fat, low glycemic choices available at fast food venues is a step. Providing tastings on site at the clinic of such foods as quinoa, kale and acai berry juice is a method that is being considered. Listening to the patient story and working in a patient provider partnership will yield the most successful strategies, particularly when the socioeconomic pressures serve as barriers to achieving goals.

Functional medicine addresses the underlying cause of disease using a systems oriented approach engaging both patient and practitioner in a therapeutic partnership. It is an evolution in the practice of medicine that better addresses healthcare needs in the 21st century. By shifting the traditional disease centered focus of medical practice to a more patient centered approach, functional medicine approaches the whole person, not just a set of symptoms. Functional medicine practitioners spend their time with patients listening to their histories and looking at interactions among genetic, environmental and life-style factors influencing long term health and complex chronic disease.

NEAETC is pleased to be the conduit of education; both the purveyor and the recipient as we reach out to all clinicians and HIV experts as well as community doctors and nurse practitioners who with “boots on the ground” knowledge understand nuances that can sometimes be forgotten.

Special thanks to John Paul Krueger, MD and Jon Fuller, MD and The Boston Medical Center.

Source: 
New England AETC
Publish Date: 
Friday, August 8, 2014
Author(s): 

New Initiatives and Updates from the United States-Mexico Border Binational Infectious Diseases Conference

USMBHCI was honored to represent the Texas/Oklahoma AIDS Education and Training Center (AETC) and the U.S.-Mexico Border AETC Steering Teem (UMBAST) this year at the United States – Mexico Border Binational Infectious Disease Conference in El Paso, Texas. This binational meeting is convened each year by the United States – Mexico Border Health Commission (BHC) in collaboration with other federal and state agencies. The Executive Director of the BHC, Jose Luis Velasco, was guest speaker at UMBAST’s recent annual meeting, and despite being relatively new in his position, is a champion of our work. I was never so happy to be bilingual as I was during the time at this conference, which was planned in such a way that every other session was in English or Spanish.  It was great to be able to understand all sessions without the need for an interpreter.

The Texas/Oklahoma AETC presented a poster on "Educating HIV/AIDS Providers along the U.S./Mexico Border." We looked at training provided along the U.S./Mexico border region since 2010 and found that 87% of participants reported that the information presented was applied in their practice/service, and 94% would recommend the training to their peers and other participants.  Based on the results of additional participant reports, we found there was an increase in participant knowledge upon completion of our trainings.

It was great to see representatives from federal, state and local levels from both sides of the border working together to address infectious diseases and minimize their effects along the border. A frequent theme was health inequalities along the border and the impact it has on each side of the border. For the context of this conference, health inequities referred to an individual without access to medical care, no or low education, someone without an employment source, no housing, basically anything that will place that individual living along the border at a health disadvantage.  What was impressive, however, was seeing the extent of collaboration to solve some of these issues. The people working daily on the border who study and address health concerns across two federal, ten state, and multiple local systems, deserve a lot of credit. 

The topics presented varied from federal to policy discussions, region-specific epidemiology updates including HIV/AIDS prevalence and incidence, HIV prevention, tuberculosis, and coccidioidomycosis. Breakout sessions were short, concise, and straight to the point, offering multiple tracks to fit the interest of participants.

A presentation that caught my interest was the panel discussion on communicable diseases in detention centers. Here, Commander Diana Elson from the U.S. Customs and Immigration Enforcement (U.S. ICE) provided a great explanation of the process an individual infected with a communicable disease, such as tuberculosis, goes through – from getting apprehended and testing positive, to treatment and being kept in isolation, if needed, at an ICE facility before finalizing the deportation process once there is a clean bill of health. UMBAST worked with Dr. Elson previously to create a fact sheet for providers of HIV patients who have been detained by U.S. ICE.

brochure coverAnother program that was mentioned throughout the conference is the Ventanilla de Salud (literally, “windows of health”) system, which is a program of the Mexican Department of Health and the Mexican Ministry of Foreign Affairs and implemented through 50+ Mexican consulates in the United States. The Ventanilla program provides health information, counseling, and referrals for Mexican nationals living in the United States. Their website offers information in English and Spanish – check to see if there is a Ventanilla program near you, and whether there are services available for your patients.

A big takeaway from this conference for me is that we have come a long way with collaboration; however, there is still room for growth between the United States and Mexico to minimize the impact of communicable diseases in this region. All of the presentations at this conference were excellent with great speakers and great sharing of ideas, but in the end one thing was clear: infectious diseases do not respect borders, sex, age, or social status. 

Texas-Oklahoma AETC’s collaborative border program includes a focus on online, on-demand training sessions, which are accessible to providers on either side of the border. We will continue to address topics that contribute to health disparities in this region, including substance abuse, TB, policy issues (Affordable Care Act, and continuity of care for deported patients) and patient- and community-focused concerns such as health literacy and cultural factors in the Latino community.

 
Source: 
Texas/Oklahoma AIDS Education and Training Center
Publish Date: 
Wednesday, July 16, 2014
Author(s): 
Author: 
Affiliation: 
Texas/Oklahoma AIDS Education and Training Center

Mortality Associated with Chronic Comorbidities among HIV-infected Persons in the United States

Combination antiretroviral therapy (cART) has substantially reduced HIV-related morbidity and mortality in the United States. HIV-infected persons today are living healthier and longer lives with expected lifespans near equal to those of uninfected person if the infection is effectively treated [1]. CDC estimates that by year 2020, over half of the HIV-infected persons in the United States will be aged 50 years or older [2]. With increased longevity, HIV-infected patients increasingly experience a variety of age-related chronic diseases [3] common in the general population, such as cardiovascular disease, liver disease, diabetes, and non-AIDS related cancers.

HIV-infected persons may experience similar or even higher rates of some of these comorbidities than HIV-uninfected persons. Reasons include the high prevalence of behavioral risk factors (e.g., tobacco use, alcohol use) and side effects of HIV-related treatments (e.g., kidney toxicity, unhealthy elevations in cholesterol). Emerging data suggest HIV itself may more directly increase risk for conditions such as atherosclerosis, low bone mineral density, and chronic obstructive pulmonary disease by stimulating a state of chronic inflammation that favors these outcomes. As a result, deaths among cART-treated persons in the United States are increasingly likely to result from non-AIDS-related causes [4,5].

Since 1993, The Centers for Disease Control and Prevention (CDC) have funded a multi-site study of HIV-infected patients cared for at HIV-specialty clinics: the HIV Outpatient Study (HOPS). In recent years, the HOPS investigators have shown that:

  • Most HOPS patients suffer from multiple chronic conditions in addition to HIV. In recent years, approximately two-thirds of HOPS patients had two or more chronic conditions in addition to HIV [3].
  • In 2004, among HOPS patients who died, 43% died solely from non-AIDS-related causes. In 1996, that percentage was 13% [4].
  • Despite persistent reductions in mortality among cART-treated HOPS patients (rates currently average at 1.6% percent per 100 persons per year, down from about 10% before 1996) disparities in mortality remain [6]. These sociodemographic disparities appear at least in part attributable to differences in the burden of chronic conditions not directly related to HIV infection. Among HOPS participants who died, comorbid conditions which may be prevented by lifestyle changes (e.g., tobacco smoking cessation, dietary changes) were often more prevalent among blacks/African Americans and Hispanics/Latinos than whites, and among publicly than privately insured participants [6].
figure 1
figure 2

As HIV-infected patients age and experience multiple comorbidities, the integration of HIV care and primary care is ever more important. HIV providers should be comfortable with standard chronic disease management and coordinate care with specialists as needed (e.g., cardiologists, nephrologists, hepatologists) while primary care providers will need to become more comfortable with the basic management of HIV infection. Because HIV-infected patients see their doctors for HIV care typically twice or more annually, HIV providers have repeated opportunities for brief messages related to chronic HIV disease prevention (e.g., including smoking cessation, exercise and weight loss) to reduce illness and death due to chronic conditions.

References:

1. Samji H, Cescon A, Hogg RS, et al for the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of IeDEA. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One. 2013; 8(12):e81355.

2. Brooks JT, Buchacz K, Gebo KA, Mermin J. HIV infection and older Americans: the public health perspective. Am J Public Health. 2012;102(8):1516-26.

3. Buchacz K, Baker RK, Palella FJ Jr, et al for the HIV Outpatient Study Investigators. Disparities in prevalence of key chronic diseases by gender and race/ethnicity among antiretroviral-treated HIV-infected adults in the US. Antivir Ther. 2013;18(1):65-75.

4. Palella FJ Jr, Baker RK, Moorman AC, et al for the HIV Outpatient Study Investigators. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr. 2006;43(1):27-34.

5. Adih WK, Selik RM, Hu X. Trends in Diseases Reported on US Death Certificates That Mentioned HIV Infection, 1996-2006. J Int Assoc Physicians AIDS Care. 2011;10(1):5-11.

6. Palella FJ Jr, Baker RK, Buchacz K, et al for the HOPS Investigators. Increased mortality among publicly insured participants in the HIV Outpatient Study despite HAART treatment. AIDS. 2011;25(15):1865-76.

Disclaimer: The findings and conclusions of this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Source: 
U.S. Centers for Disease Control and Prevention
Publish Date: 
Wednesday, June 18, 2014
Author(s): 
Author: 
Affiliation: 
U.S. Centers for Disease Control and Prevention

Mental Health Awareness: How Aware Are We?

May was Mental Health Awareness month.  How aware of mental health issues are we in our own lives as well as in those we treat every day?  As HIV care providers, how often do we hear “I am so down,”  “I haven’t had fun in so long,” or “I’m so stressed.”  Often in our patient’s lives everything becomes a problem, so do we truly recognize the stress they may be experiencing?  With clinic visits becoming shorter and patient volume growing larger, checking in on a person’s mood often falls by the wayside. 

Studies vary on the prevalence (0 – 80%) but most agree the incidence of depression in the HIV-infected population is similar to other chronic illnesses.  If this is correct, 25-30% of our patients meet the criteria for Major Depression.   Many more transiently feel “down” and could benefit from intervention of some sort, which may vary from some type of interpersonal therapy to psychopharmacologic intervention.  Screening tools become an important part of the patient visit to identify those who need further interventions.  Many tools are available and should be chosen based on ease of administration, and time for completion.  A short list includes Beck Depression Inventory -II (BDI-II), Brief Symptom Inventory (BSI), and the Patient Health Questionnaire (PHQ-9).  In states with Medicaid expansion and more aggressive Affordable Care Act rollout, the ability to intervene has increased.  For states without Medicaid expansion and fewer resources, mental health services remain status quo. Therefore, in states without Medicaid expansion, it behooves the Primary Care Provider (PCP) to learn about and use these resources.  Waiting for the initial psychiatric or therapy appointment to intervene is a waste of valuable therapeutic time.   Utilizing self-report screening tools allows providers to determine who needs further attention.  Referring case managers familiar with mental health issues then provides another level of support.  They can further assess the individual during the visit, and   make treatment recommendations for the provider to intervene. 

In these situations, it is important to for the PCP to understand how to use a few antidepressants/anti-anxiety medications.  There are many relatively safe medications that have few interactions with antiretrovirals. It is also important to know where the HIV-infected individual can be referred locally for therapy, as not all interventions need to be pharmacologic.  Starting medications may be sufficient without need for psychiatric referrals.  Following up with tools that assess progress on each visit or a phone call can help determine more intensive intervention (psychiatric referral).  For example, both the Beck Depression Inventory –II, and the Patient Health Questionnaire have been validated for interval use demonstrating progress of treatment. 

Treatment of mental health issues (specifically depression) is important for effective treatment of HIV.  With few treatment options, Primary Care Providers need to take more of a lead with treatment to assure positive patient outcomes. 

Source: 
Texas/Oklahoma AIDS Education and Training Center
Publish Date: 
Wednesday, June 4, 2014
Author(s): 
Affiliation: 
Texas/Oklahoma AIDS Education and Training Center

Health Care Reform and its Impact on People Living with HIV/AIDS - The Massachusetts Experience

In 2006, Massachusetts passed comprehensive health insurance reform in order to provide almost universal coverage for its residents. In doing so, the state introduced several health care reforms, which have become the foundation for the Affordable Care Act (ACA) and made MA the model for the Ryan White Program in a post-health care reform environment. Reforms included an individual mandate, Medicaid expansion, and increased access to subsidized private insurance and resulted in improved health outcomes and reduced health care costs for all residents. 

In 2001, Massachusetts became the first state in the nation to implement a federal waiver allowing Medicaid expansion to non-disabled people living with HIV (PLWH) with incomes up to 200% of the Federal Poverty Level (FPL). In 2006, Massachusetts became the first state to mandate that all residents carry health insurance coverage. These reforms allowed for subsidies for residents with incomes up to 300% of the FPL, and included the development of the first state health insurance exchange that certified plans with comprehensive benefits without preexisting condition exclusions. Additionally, the reforms preserved a comprehensive Medicaid benefits package for all residents, and the expansion of Medicaid to cover all uninsured residents with incomes up to 200% of the FPL. 

With local health care reform, Massachusetts has seen an impact on its Ryan White Program. Since 2006, funding to Massachusetts’s HIV Drug Assistance Program (HDAP) has been largely spent on health insurance plans and medication co-pays. The HDAP has maintained an unrestricted formulary and 500% FPL eligibility. The HDAP serves as a resource for ensuring Medicaid enrollment, as applicants must use the HDAP as the payer of last resort and show proof of having applied for Medicaid. In 2007, Massachusetts became the first state to receive a waiver to the 75/25 rule, which allows it to invest heavily in critical coverage completion services (such as medical case management and psychosocial support services) that are non-third-party reimbursable, but essential to ensure that PLWH are engaged, retained, and adherent to care. As a result of expanded insurance coverage, access to antiretroviral therapy, and a robust HIV provider network, including Ryan White-funded services, Massachusetts has seen a decline in new HIV diagnoses and has also achieved very high levels of viral suppression.

It is important to note that while the ACA will result in expanded access to health care for PLWH, as we have seen in Massachusetts, it will not address all needs PLWH face. Therefore, the Ryan White Program will continue to play a critical role in serving the needs of PLWH. Particularly, going forward with the ACA, the Ryan White Program will need to provide coverage completion services and continue to provide a full range of critical services for those who have no other source of coverage, including undocumented PLWH and legal residents living with HIV who are not yet eligible for public coverage. 

Source: 
New England AETC
Publish Date: 
Wednesday, May 21, 2014
Author(s): 
Affiliation: 
New England AETC

Sexual Transmission of Hepatitis C in HIV-Infected MSM: Raising Awareness through Screening

May is National Viral Hepatitis Awareness Month. We are at an exciting time in HCV awareness, screening and treatment. A recently updated Viral Hepatitis Action Plan, new United States Preventative Services Task Force (USPSTF) HCV screening guidelines for both the birth-cohort (the “baby boomer” guidelines of providing a one-time test for anyone born between 1945 and 1965) and risk-based populations, and advances in HCV treatments have brought a renewed focus to this historically “silent epidemic."  With at least 2.7 million people chronically infected, HCV is the most common blood-borne infection in the United States.

It is also the deadliest: HCV accounts for at least 15,000 deaths per year, and is the leading indicator for liver transplants in the U.S. It is estimated that at least 300,000 or 25% of people living with HIV are also infected with HCV. HCV-related liver disease is the leading non-AIDS cause of death in HIV-infected patients, and HCV disease progression is more rapid in this group, making detection of both acute and chronic HCV extremely important in clinical practice.

Injection drug use remains the most common risk factor for HCV, but in HIV-infected persons — particularly in MSM populations — sexual transmission is a significant risk factor. Sexual transmission of HCV among HIV-infected MSM has been consistently reported in medical literature since the early 2000s, but screening recommendations for the sexual transmission of HCV are not included in the CDC risk-based or birth cohort guidelines, nor are they in the USPSTF guidelines.

However, the CDC’s 2010 Sexually Transmitted Diseases Treatment Guidelines provide excellent guidance for HCV screening in HIV-infected patients. In addition to recommending HCV screening upon initial evaluation, these recommendations also call for routine monitoring of liver function tests to identify acute HCV infection. Finally, to account for the risk of possible sexual exposure in HIV-infected MSM, they suggest HCV testing at either routine intervals or when a patient presents with an ulcerative STD.

Guidelines for frequency of HCV screening have not been established, but the following list of risk exposures for HCV suggest a need for frequent screening (every 3-6 months, but at least annually):

  • Patients who report sharing injection drug using equipment (syringes, cookers, cotton, water, etc.);
  • Patients who report sharing non-injectable drugs (crack/crystal meth pipes, snorting straws), especially when used in conjunction with sex;
  • Patients who report sexual activity likely to cause trauma or bleeding from breaks in rectal tissues (such as fisting, multiple sex partners, use of sex toys);
  • Patients who report bleeding during anal sex;
  • Patients who report not using, or not consistently using barriers during anal sex (condoms, gloves for fisting);
  • Patients who practice serosorting;
  • Patients with a history of genital ulcerative diseases (HCV, LGV, primary syphilis).

HCV screening toolkitProject Inform can help your patients who are living with HIV/HCV co-infection, or are at risk of HCV infection. We have developed a three-booklet Health and Wellness series for patients living with HIV and HCV.

Additionally, you can direct your patients to a national hepatitis C helpline, Help-4-Hep at 1-877-Help-4-Hep (877-435-7443). Trained counselors and health educators are available to talk with your patients Monday-Friday, 9am to 7pm EST. You can also order Help-4-Hep posters, brochures and tear pads online.

This month, Project Inform also plans to launch “A Toolkit for Screening, Counseling and Patient Education: Hepatitis C Infection and People Living with HIV," which includes materials for medical providers and other health care staff as well as patient fact sheets. For more information on this toolkit or to request a free copy, visit the Project Inform website, or email Andrew Reynolds, Hepatitis C Education Manager, at areynolds@projectinform.org.

Source: 
Project Inform
Publish Date: 
Wednesday, May 7, 2014
Author(s): 
Affiliation: 
Project Inform

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