Special Coverage of the 2000 IDSA Conference
Clinical care of HIV patients needs comprehensive approach
Comorbidities, drug reactions complicate treatment
While there were no earth-shattering breakthroughs or discoveries on HIV presented at the recent Infectious Diseases Society of America (IDSA) conference, the HIV-related presentations made it clear that clinicians have reached a fork in the road of HIV care. They may continue with the piecemeal approach to care that focuses primarily on the HIV disease itself, or they can enter the new age of HIV treatment that calls for caregivers to treat all of the HIV patient’s medical needs.
Much of the new research presented at the Sept. 7-10 conference in New Orleans involved studies of HIV patients with comorbidities and medical problems that may or may not be the result of sustained antiretroviral treatment.
"We have for a long time in HIV care focused our attention on opportunistic infections and antiretrovirals," says M. Keith Rawlings, MD, associate medical director of Parkland Health and Hospital Systems at Southeast Dallas Health Center.
"Now these same clinicians have to be more and more attuned to general medical management of the patient’s hypertension, diabetes, and other kinds of medical management issues," Rawlings notes.
For instance, the increase in the number of women with HIV means HIV clinicians will now be caring for more women patients, who will need regular Pap smears, Rawlings suggests.
Another study introduced at the IDSA conference that examined the incidence of cervical carcinoma in HIV patients found a trend of a higher incidence of the disease in HIV-infected women from 1996 to 1999 than from 1992 to 1995.1 While not statistically significant, the increase at least suggests it’s a good policy to recommend annual Pap smears to HIV-infected women.
"Perhaps clinicians should adhere to a recommendation of yearly Pap smears for HIV-infected women and have a more vigilant attitude toward minority groups such as Hispanics and African-Americans," says Regis Vilchez, MD, a research fellow and member of the Baylor Center of AIDS Research at the Baylor College of Medicine in Houston. Vilchez was an investigator on the study of four AIDS-related malignancies.
Kaposi’s sarcoma incidence has declined
The malignancy study confirmed that the incidence of Kaposi’s sarcoma decreased significantly in the later period when highly active antiretroviral treatment (HAART) became available. But there was a statistically insignificant decrease in non-Hodgkin’s lymphoma and a statistically significant increase in the incidence of Hodgkin’s disease.
"It is a complicated issue, but in light of observations, it appears antiretroviral therapy influences Kaposi’s sarcoma. But we cannot conclusively say it has had an impact with the other malignancies," Vilchez says.
The Centers for Disease Control and Prevention in Atlanta also published research this year in the Journal of Acquired Immune Deficiency Syndrome, confirming that the incidence of Kaposi’s sarcoma has been declining in the United States due to combination antiretroviral therapies.
However, HAART hasn’t eliminated Kaposi’s sarcoma and apparently has no impact on the three other malignancies included in the Baylor study. The fact that HIV patients continue to develop serious malignancies is an important point to consider when treating this population, Vilchez says.
"AIDS-related malignancies are an important component of the opportunistic infections [OIs] that one can expect in patients on HAART," he says. "Indeed, malignancies have become the most important cause of mortality among AIDS patients in the United States."
Malignancies are now more important causes of death among the AIDS population than are pneumonia, cryptococcal meningitis, and progressive multifocal leukoencephalopathy, Vilchez adds.
However, HAART still is relatively new, and decades from now it’s possible HIV patients will die of comorbid conditions, such as heart disease and diabetes, more readily than they do of OIs, some experts say.
"If you think about it, HIV behaves more like a chronic medical disease than it does an infectious disease, and in many cases what we’re now asking our HIV experts to be is primary care physicians, and not just for HIV, but for all medical problems," Rawlings adds.
Rawlings was a chief investigator of a study that analyzed the comorbidities and clinical indicators of a group of HIV-positive patients between 1996 and 1999. Investigators found that there was an increase in the average number of comorbid conditions among the 335 patients in the cohort study. The average number of comorbidities per patient increased from 1.11 in 1996 to 1.92 in 1999. The percentage of patients who had no comorbidities decreased from 33.7% in 1996 to 15.2% in 1999.2
"The notion that we have this population that has nothing wrong with them except HIV isn’t really true," Rawlings says. "The number of things that were wrong with them as a comorbid issue, not as a side-effect issue, was increasing."
HAART may not be to blame for comorbidities
The Dallas study draws no conclusions about the cause of the increase in comorbidities. Rawlings says he doesn’t believe it’s valid to assume comorbidities have increased as a side effect of HAART.
"If you’re seeing more and more women becoming infected, it shouldn’t be surprising that you’re having more hospitalizations for pregnancy and cervical dysplasia," Rawlings says. "And if you’re seeing more and more minorities, then it shouldn’t be a surprise that there are more hypertension and hyperlipidemia cases."
Regardless of whether the comorbidity increase is a result of changes in patient demographics or the use of HAART, the fact remains that the nature of HIV care is changing, Rawlings adds.
For example, HIV clinicians now also need to be aware of the possibility of osteoporosis or other bone diseases among their patients. This is a disease that may never been considered an issue even worth mentioning pre-HAART.
National Institutes of Health (NIH) research and other recent studies have suggested that HIV patients on HAART may be at greater risk for developing osteonecrosis.
Additionally, a pilot study conducted at the University of North Texas Health Science Center in Fort Worth showed decreased bone density and an increased risk of fracture among a small cohort of HIV-infected patients.
HIV patients had other comorbidity risk factors
"Many women in the study were predisposed to having osteoporosis separate from whether they were HIV-infected," says Bernard R. Rubin, DO, professor of medicine and chief of the division of rheumatology at the University of North Texas Health Sciences Center.
Some of the women were post-menopausal, and others had anorexia, bulimia, a poor dietary intake of calcium, or a strong family history of bone loss, Rubin says.
HIV-infected men included in the pilot study also had signs of decreased bone density. Most of the time, the cause is hypogonadism, Rubin adds.
The research suggests that people severely ill with HIV are prone to bone disease independent of their age. The average age of the 12 women and 17 men included in the study was 33 years. Bone scans were abnormal in 16 people who were less than 40 years of age.3 "We found people in their 20s and 30s with bones as brittle as older people," Rubin says.
Researchers are continuing the study, looking at a larger population of 60 patients, says Barbara A. Atkinson, DO, a co-author of the abstract and chief of infectious disease and associate professor at the University of North Texas Health Sciences Center.
Atkinson cautions clinicians not to draw too many conclusions about changing treatment based on the limited study, but to continue to follow osteoporosis guidelines of scanning all post-menopausal women for bone density loss.
There are treatments available for male and female HIV patients who have osteoporosis or bone density loss. These include Alendronate, which has been approved by the U.S. Food and Drug Administration for management of postmenopausal osteoporosis.
"Alendronate is not a hormone, and it works in men, too," Rubin says. "So now we have a drug for either sex."
Other HIV research relating to comorbidities and OIs presented at the IDSA conference included a study of cardiovascular risk in HIV-infected people and a look at progressive multifocal leukoencephalopathy (PML) in the pre-HAART and post-HAART eras.
The cardiovascular study, coming from the University of Cincinnati College of Medicine, concluded that HIV-infected patients may have cardiovascular disease, but it’s associated with traditional risk factors. That study found no clear evidence that using protease inhibitors increased patients’ risk for cardiovascular disease.4
Team approach may work best
With the strong possibility that HIV patients may have comorbidities, such as heart disease, bone density loss, PML, or malignancies, clinicians probably are best off treating these patients through a team approach, Vilchez and Rawlings say.
"There will have to be a dual-management approach, so it’s important for me to have access to a cardiologist who is familiar with HIV management, and I need to be familiar with the cardiovascular management, so we are able to provide care that is appropriate for the entire spectrum of illness that a patient has," Rawlings says.
Rawlings, who has worked with HIV patients for more than a decade, often has HIV-infected patients referred to him who have diabetes, high blood pressure, and heart disease. "If a colleague identifies an HIV-positive patient, they will refer that patient to me and my team to follow this individual, even if HIV is the least of this patient’s problems," he notes.
While Rawlings chooses to provide general medical care to HIV patients, some physicians live in areas where there are few alternatives. These physicians have little choice but to provide most of the medical care their HIV patients need, and they especially need to be aware of comorbidities and the changes among OIs, Vilchez says.
"This was a point brought up at IDSA: A substantial number of physicians taking care of HIV infection are generalists, individuals who have been trained as family or internist physicians," Vilchez says. "They have the load of taking care of these patients in rural or suburban areas, and I believe they need to be aware of this issue."
References
1. Vilchez R, Kozinetz C, Kroll MH, Butel JS. The influence of antiretroviral therapy on the incidence of four AIDS-related malignancies in a large urban center. Abstract #376 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
2. Rawlings MK, De Guzman C, Slaker R, et al. Comorbidity and clinical indicators in a cohort of 335 HIV+ patients 1996-1999. Abstract #324 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
3. Atkinson BA, Blais FX, Rubin BR, et al. A pilot study to define the degree of loss of bone mass in HIV infected individuals. Abstract #356 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
4. David MH, Fichtenbaum CJ. A case-control study of cardiovascular risk in persons with HIV infection. Abstract #355 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content